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EL C49 505

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LCCUMENT ESUME

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PIBI INF( 001 \ I toN N(.I IN.\ 1 10N \l, INs 1111 11 01 \II N"I \1.111

Alcoholand

AlcoholismNATIONAL INSTITUTE OF MENTAL HEALTH

National Cffiter for Prevention and Control of AlcoholismChevy Chase, Maryland 20203

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PUBLIC IIEAL-1 II SERVICE PUBLICATION NO. 1610

tVashington, 20102. plifC 50 centsFor Salo by the Soprrinteilittnt of Dotiirneiwt. 17. S. Golttnincnt Printing Officc

4

FOREWORD

No other national health problem has been so seriously neglected asalcoholism. Many doctors decline to accept alcoholics as patients. Mosthospit.als refuse to admit alcoholics. Available methods of treatment havenot been widely applied. Research on alcoholism and excessive drinkinghas received virtually no significant support.

The atmosphere of moral disapproval surrounding the entire subject,and the deplorable custom of treating alcoholics as sinnets or criminalshave obscured the nature of the problem.

But now we recognize that alcoholism is an illnessno more moral orimmoral than tuberculosis or pneumonia or schizophrenia- -and that ourways of dealing with that illness have been shockingly inadequate.

At the direction of President Johnson, the Department of Health, Educa-tion, and Welfare is now developing a comprehensive program a-red atcontrol and prevention of alcoholism and at providing sound, o...jectiveinformation about the problem,

This report surveys the present state of our knowledge of alcoholism,based on the best scientific infolinatio» ava;lable. It represents a major steptoward understanding and eventual control.

1011N W. GARDNER

Secretary of Health, Education, and Welfare

tut

ACK NOIFI,EDGMEA'TS

The National Institute of Mental Health extends its appreciation to thefollcwing for their guidance and assistance in the preparation of thismonograph:

Dr. Waiter A/ raze', Chicago: Dr. Seller Bacon, Rutgers University; Dr.Marvin Block, Albany Medical College; Dr. Mortis E. Chafeu, Nlassacho-setts General Hospital; Dr. Charles Das idson, Harvard University; Dr.William Dock, State Univeisity of New Yolk; Dr. Olof Forsander, Finn-ish State Alcohol NIonoroly, Helsinki: 1)r. Ruth Fox, National Council onAlcoholism; Dr. Verbelie Fox, Georgiao Clinic, Atlanta; Dr, LeonardGoldberg, Karolinska Institute. Stockholm; Dr. Leon Greenberg. RutgersUniversity; Dr. Jack Gordon, Mount kion Hospital. San Francisco: Dr.Joseph Hirsh, Albeit Einstein College of :Medicine; Dr. Ebbe Caulk Hoff,Medical College of Virginia: Mark Keller, Rutgers University; Dr. John C.Krantr, Jr., Universir Mary /and; Dr. Marcus Krupp, Pal.) Alto MedicalResearch Foundation; Dr. Cha,:nrey D. Leake, University of California;Dr. Giorgio Lolii, hatemational Center for Psychoclietetics, New Volk; Dr.George L. Maddox, Jr., Duke UniscE,ity; Dr. John R. Philp, Kansas CityHealth Department; Lewis Presnall, National Council on Alcoholism: Dr,Milton Silverman, Department of Health, Education, and Welfare: Dr.Robert Straus, University of Kentuck); and Wayne Wi lle, National Safety

PREFACE

Today Americans live in a culture in whit,. the use of alcoholic bever-ages is widely, though not universally, accepted. Yet, at the same time, themisuse of alcohol represents a public health problem of major significance.The effects of excessive drinking on one individual, tragic as they may be,indicate only one aspect of the problem; they are .-ompounded by theeffects of his behavior on his family, his friends, his fellow-workers and hisneighbors. In the aggregate, our entire society is concerned.

It is evident that we have been unable to find any simple remedy forthis problem through legal or moral pressures. It is equally evident thatthe reined) does not lie simply in treating those who have already becomeaddicted to alcohol, since the provision of adequate manpower and facili-ties to treat all alcoholics with presently known methods on a one-to-onebasis would in inelf utilize the full time o[ every physician and fill everyhospital bed in the Nation.

Clearly, we cannot ignore those who are already victims o[ alcoholism.Much effort is required to utilize fully for them the best therapeutic meth-ods now available, and to develop and test improved methods for thefuture. But it is obvious that the eventual contiol of alcoholism must de-pend primarily on the prevention of alcoholism.

Before alcoholism can be prevented, it must he understood. We urgentlyrequire research to clarify our understanding of the complex causative fac-tors. We require research to provide an understanding of the physical,psychological and social effects of alcohol. We requite research to developand test techniquesbiochemical, psychological, educational, sociologicaluuI perhaps 0E1121-swhich might have value in prevention. For full effec-tiveness, these must be broadly based ins estigarions: they must coneeinthinking rather than only alcoholism, alcoholic beverages rather than onlyalcohol, and actual life situations ?miter than only laboratory experiments.

Research in these vat ious fields is telatiyely new. More needs to be donein universities, research centers, hospitals, community health centers, indus-trial organizations, and many governmental agencies. In the Federal Ciov-mitten', the Public Health Service's National Institute of Mental Healthhas had major responsibility for the support of iesealch on alcohol andalcoholism, denionstratiop Provo ams, training and control activities. Now,by direction of President Johnson, a National Celtic] for the Piesentionand Control o[ Alcoholism has been established at the institute, throughwhich many of these activities can be vigorously and creatively directed andcoordinated.

In addition, it is equally impottant that the public be itifonned, 'I heresults of research wouhl be largely wasted unless they could be communi.

7VII

rated to the adults and the young people in our society whose welfare maybe intimately involved, It is important for them to lecngnize, for example,that much of what has been popularly believed in this field is not sup-ported by modern knowledge. It is important for then] to realize that thereare treatment methods now available which can be effective. It is importantfor them to know that how much one drinks may be less important thanwhen he drinks, how lie drinks, and why he drinks.

This report marks one of the first steps in this new, broad program ofinformation. Rather than a complete and completely documented treatise,it is a relatively brief survey. It presents some of the highlights of modemresearch on drinking and alcoholism, as based on technical articles pub-fished in the scientific literature and the views expressed by leading author-ities in the field.

From this report, it will be obvious that much knowledge has beenacquired, but that more is needed. There are evident gaps in our knowl-edge, and accordingly there is still controversy and confusion which can beremedied only by further investigation.

It will also be obvions that successful programs for the treatment, controland prevention of alcoholism will require unprecedented public under-standing, public support and public participation.

STANLEY F. YOLLF.S, MD.Director

National Institute of Mental Health

JAnt. H. MFNDELSON, M.D.Chief, National Center for Prevention

and Control of AlcoholismNational Institute of Mental Health

8

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TABLE OE CONTENTSFOREWORD . iii

ACKNOWLEDGMENTSPREFACE . vii

I. HISTORYThe New Look at DrinkingAt the Beginning ... 2

Why People Drink 2

Excessive Drinking ..

II. EXCESSIVE DRINKING: NATURE OF THEPROBLEM .. 5

The "Drinking Problem" 5'Pie Problem Drinkers .. 5

Alcoholics: Definition .. 6

Disease or Self-Indulgence's 6The Habitat of Alcoholics: "rhe Skid Row MrtliConsumption by Alcoholics: The "Safel.evel" Myth . 8

III. EXCESSIVE DRINKING: SCOPE OF THEPROBLEM .. 9

The Number of Drinkers 9The Number of Problem Drinkers 10

The Number of Alcoholics . 10

Sex DifferencesRegional Alcoholism Rates 10Risk of Alcoholism . 11

'Frends in Alcoholism Rates I 1

Alcoholism Deaths . . 11

Traffic Accidents 12

The Cost to Industry . ISAlcohol and Crime ..... 13Alcohol and Brain Damage 14.....Alcohol and Family Problems 14

Teenage Drinking 14

IV. THE CHEMICAL COMPOSITION OF ALCOHOLICBEVERAGES 17

The "Cnigenets" 17

The Fusel Oils . 18

The Value of Chemical Data 18

2,337 I) RI 2

9IX

V. EFFECTS OF ALCOHOLIC BEVERAGES ON THEBODY 19

Absorption 19

20

Excretion .20

Stimulant cr DepiessanC 20

Effects on the Brain 21

Effects on Skilled Pet fonnance 22Elects on the Liver . 22Effects on Other Organs 22Deficiency Diseases . 22Resistance to Infection . 23

Gout .23

The flangover 23

Effects on Longevit) 23

VI. CAUSES OF ALCOHOLISM 24

Physiulogiral Factors .. 24P:cyc holo,gical Etc tors 25

Sociological Factors 25

VII. DIAGNOSIS OF ALCOHOLISM 29

"he Warning Signs 29Tile Diagnostic Tlaps 30

VIII. TREATMENT OF :ALCOHOLISM 31

eliminal) Tieittnient 31

Hospital .\dmission 32

141iig lictap) 33

Psy, hot het apy 331 he 1 liempist 31

The Chi gy, I'll) .,icians, 31-35Other Specialists, Special Family \id 36

Individual is. Group 1 hrtaps 36Chances of Rewico. 37The Rote of hichisit 38

he Role of Ifealth 105in:ince 381 he Role of I1 .1gettLies 39Tice Role of State and Federal .pentics , 39

IX. PREVENTION OF ALCO/I0I,ISNI 41

Legal Appioaclics: Nazi mat ItAppolaclics: Regional . 11

Legal AppioNlit.s: 'Hie Vomit!, Drinkers 12

Religious .1ppurac hc, 2teltuation: Against Alcohol 13Education: Vol Site Diiiiking 44

10

X. CURRENT ACTIVITIES: SURVEYS ANDSERVICES .. 46

Survey of the Problem . 46Treatment and Rehabilitation FacilitiesCommunity' Mental Elealth Centers 48T;chnical Training 48Community Education :',nd Organi/ation 49

XI. CURRENT ACTIVITIES: LABORATORY ANDCLINICAL RESEARCH .. 51

Effects of Alcohol 51

Physiological Factors in Alcoholism 52Alcoholism in Experimental :.nimals 53Research on Therapeutic Methods 54

XII. FUTCRE NEEDS 57

Application of Present Knowledge 57Search for New Knowledge . 58

X1II. THE NATIONAL. PROGRAM 60

The Plesidentird Directive . 60The flea lih, Education. and Welfare Pm ograin . 60Intragovcrnmental Coordination hiNational Action Policy 62Reseal ch 62Education 63Delivery of Services h3

BIBLIOGRAPHY.

65

Si rGGESTED SUPPLEMENTARY READING 73

11

X1

Alcohol and Alcoholism

r. HISTORYThe use and misuse of akoholic beverages is a major subject of contro-

versy in America, It has nearly always been so.Efforts to «mnol di inking Itasc langed fious sermons form the pulpit and

adyice from physicians to judgments by the courts. Fhe very political cli-mate of the Nation has been shaped by attitudes about drinking--attitudesas disparate as those which brought about the Whiskey Rebellion of !791and the Vo1stead Ac t of 1919.

Arnetica has !tied nationwide prohibition by. Federal law and reicctedit Today, it is generally accepted that those adults who wish to think hatea right to do so, limited b. local customs defined by either written orunwtitten ljs Inn legal tights, written or unwritten, are not the onlyfactots invoked. Social rights and social pressures are also comerned, andthese may vat) widely in dillerent groups and different regions.

Under these ciicumstanms, there is no one natiomi actinide toward mod-erate cr.- social thinking that is acceptable to evelyotco, Perhaps Own, willneetr be such agreement. Rut thew is developing a common attitude eon-(cluing the excessive di inker, the problem drinker, and the alcc,holie. Thisis based in part on the glowing awaleness tha the problem of excessivedrinking in this cumin).- is of serious proportion,. It is based also on thegrowing recognition that al(oholism and excessive thinking iepresent notsimply moral issues but tnedital problems with «mil-Ahmed and interre-lated chemical, pInslolcrical, psychological, and sociological aspects As suchserious and comple:s, problems, they requite (men) examination.

The New book at DrinkingThis new look at thinking is not a renewal of hostilities between "wets''

amt Instead, thew seems to be an ,-ipptec;,ition runong manythoughtful peopleincluding scientists. physicians, educators, jurists andreligious !cadetsthat solution of thinking-Rimed problems requires anundoodandim, of drinking in its many complex [wets. It is essential toern cider not pure alcohol itself (which is almost unknown outside thelaboratory), but the themistp, and the physiological effects of the alcoholicbesemges construed in real life by teal people, as well as timeand so( tolot4i(al in ditations to a so( icty in width aktinewe. moderatechinking, ex( cssiye ,pinking and riltoholistn all (cum as normal or ribnot

behavi. r:11 pattrins, It is likewise essential to tonsider the mc'ute ofthe problems and lLrir scope, to assess their nue impact on Attach; II 01.

dCly, anti to alike Iluough study IC,CAtt II at lieu' knowccdge that can

12 1

help prevent and control cxcessive chinking .111(1 simultaneously improvethe treatment awl rehabilitation of the alcoholic.

At the BeginningEven though %vides/neat' public aWall'IleSS of drinking problems is new,

the existence of alcohol is exceedingly old.As with such nattnal phenomena as fire and water, the discovery of alco-

holic bevel ages cannot he assigned a II or a patent number, nor creditedto any man or place. Only a few th. .c ingredients--sugar, water, yeastand a mild degtee of ,arnitli------;111' required for alcohol production. 11 'herethese occur together, it is virtually impossible for alcohol Prot to be pro-duced. .tccording to paleontologists, all four %vele present on earth inl'aleo/oic times, at least 200 million tears ago,

It seems obvious. therefore. that ill preceded matt and that he beganto use it long before the beginnings of written bistro y. Since the richestcivilisations, alcoholic licletages have been ieived as intuitions foods, valu-able medicines and sacred liquids for religious cep...monies.

Why People Drinkit is generally accepted today that ahohol. by strict definition, is a food.

since it is a source of ,-alotiesNo Like some other nutrients, it is not a per-fect food: it contains no .itamins and is harmful tvlien used to excess.

.11coliolic beverages have 0 long iccold of medical use and were at onetime among the most widely pies( iibed (hugs. (Here, it should he enticha-si/ed, a drug is defined as any substancesuch as aspirin, cortisone, peni-cillin or thyroid extractused for the prevention or treatment of disease.)It is still accepted that ;limbo! may serve as a useful, although not a cdra-dye, medical agent. \\ Aide some of the health values once attributed to beer,wine and distilled spirits have been ''nroved. °diets have been confirmedby modem scientific study. For exa,ople, certain alcoholic beverages arenow bring used by physicians in the diet of diabetic patients, since alcohol,unlike sugar. does not iequire insulin for metabolism. They are also usedby SI/Ille 1111)Si(1;111S ;LS lid', in the treatment of arthritis, digestive diseases.high blood piessine and «tiotwiy disease, and as liamptili/eis or sedativestor convalescent and get iatric patients.10

In one foul] or another. alcohol was probably the first tialiquililcr knownto human beings and ,e111;iiiis today the most widely usedio et

'ill(' drinking of 311tholit hesetagcs has long 1)(vil establishol as 0 pailof many religious Iitcs. 111(1 continues in that 1011.

In the niajolity of instant us, howeeer, chilaing stems flout the desire foran antidote to unpleasant teality. 11w need for an (go booster, or as all aidto sociability' and simple picasine. Quite ;watt from any physiologicalellects, the custom of chinking has often been felt to 1w 1ewattling becauseof the social inlet telationships, the status, and the beltleiots and attitudesthat accompany it

F..xcessi'c 1)rinkinglitoughotit the histuly nl .11(4,1101i( bevelages, dionkcliness has been

tonsidcied a ploblein (although Clete have 10'111 times %elicit it was acceptedand e1c11 highly appioNed),

2 13

One of the oldest temperance tracts on record was written in Egypt about3,000 years ago, under the title of 1 l'isclom of Rai:

Fake not upon thyself to drink a jug of beer," it advocated. "Thouspeakest, and an unintelligible utterance issewth from thy mouth. If thoufattest down and thy limbs break. time is none to hold out a hand CrThy companions in drink st:anl up and say: 'Away with this sot.' Anci thouart like a Hid^ child." 11 7

Similar sentiments in Greek, Roman. Indian, Japanese and Chinesewritings, and in both the Old aid New Testaments, denounce excessivedrinking

A I oholic beverages probably known it-. the New 1Vollet long beforeColumbus. "They Iv, to ceitainls brought to ,1inet ilea in 1007 with the settlingof the N'irginia Colony. Twelve years later their excessive use was such thata law decree, that any person lound drunk for the first time was to he re-poved privately by the inin;.:.ut: the second time publicly; the third rimeto 'lye in halter" for twelve ?tours ;tnd [Key a fine. Vet in the same year,the Virginia Assembls passed other legislation encouraging the productionof wines and distilled spirits in the colony.

1s one modern historian has noted. "It was not the custom of drinkingthat was unacceptable in early N'irgi ,ia. but drinking to excess."05

In the Massachusetts Bay Colony., brewing come to rank next in impor-tance to milling and baking, There, .es in Virginia. occasional drunkennesswas ptwished by whipping, fines and confinement in the stocks. Btu, asNorbert Kelly writes. I he Putitans !wither disdained not prohibited theuse of beverage alcohol. They were emphatic. however. in urging modera-tion in drinking." 65

The temperance mosernent--which sprang in considerable measure fromthe alcoholic excesses of the Industrial Revolution in Englandwas notlong in coming to America It began with the goal of temperance in itsliteral sense: modcratiniikt the peak of this catty campaign. in thetemperance leaders many of whom theinsulses thank beer and wine-maintained that tlw remedy for intempethme was abstinence from distigedspirits only."

But the next decades Inought a significant change. The meaning of tem-perance was gradually :ducted hone modetation to total abstinence. Allalcoholic beverages \vete auac tad as tmecessaiy, hatinftil to health andinhetently poisonous. The demand ;nose for total prohibition.

This demand culminated in the Inited States in the passage of dr- ISth.Amendment, which prohibited the manilla( title :Ind sale of all al«vholicbeverages. Beginning in 1920, natiowil pthhibition lasted until 1933. Evennow. neatly 31% yeas,' later, Piohibitiod remains a cuelnosetsiat subject.Its defenders claim that it !nought substantial tedtutiem in thinking. adecease in di uukcnness, amt marked economic inquovenunt to the «met-tty. 't hose who oppose the concept say that the experiment umbel °Hs themodetate drinker and !nought new and clangtmi,, ,lemur lo di inking andintoxication. .T hey claim that it destiosed public respect for law-enrolee-went offiecas and bled the (time, siolence and gunci:11 Imiupti)31 &AIItialkul the bootlegging of illicit fiquot.I2

11'hateVer the Validity of these views, me fact seemed fairly welt est..11)

lished by the end of the Prohibition era: many Americans liked to drinkand WOold insist with considerable vehemence on their right to drink.There were no signs that their Views had changed to any extent by the1960's.

But, while it has become clear that Many and perhaps most Americanswould continue to insist on their right to drink, it has also become evidentthat many Americans are drinking to excess, and endangering the lives andthe welfare of themselves, their families, and all those around them. Theproblem of alcoholism, in fact, is now recognised as a serious public healthproblem that urvntly demands intelligent, practical action based on betterknowledge of its causes and potential cures,

15

II. EXCESSIVE I)RINKING:NATURE OF THE PROBLEM

The overwhelming majority of drinkers in the United Statesan esti-tinted 90 percent of them '.,1 base apparently learned to consume alcoholicBeverages without significant ha/aid to themselves, their families Or society.Vet the problems caused by the lel:lively few who have chosen neitherabstinence nor moderation, but have become excessive or jnoblem drinkers,affect the entire ,Nmerican society. ..klthough the tan.° of problem drinkersto the total popalation is relatively small, their numbers are large. "[hemisery they cause themselves and others is enormous.

The -Drinking Problem"Sociologists have enThasiied that a major pale of the drinking problem

is deriding who and who is not a "problem thinker, for the label is ap-plied (Mica ently 1rt various cultural and social groups.

Thus, among those religions groups which devoutly believe in ccmpleteabstention, anyone who drinks is a problem drinker. Among groups thatconsider heavy di inking to be normal and even a proof of maim ityas inFrench Normandy and Brittany, in some American social groups, and insome Vocations it is the abstainer or light drinker who is singled out forattention. Groups that socially sanction only communal drinking considerthe nian who drink, alone to have a jnoblem. In some Northetu Europeangroups which socially approve of only distilled spirits, the seine drinker isregarded as a problem thinker. But in Southern European societies whichfavor only wine or beer, the drinker of "hard Ii9nor" is viewed as having adrinking problem.

In most areas of the United States where laws prohibit the sale of alto-hol to anyone under the age of 21. the 17-teat -old who chinks may be cam-sidered a problem by his elders, while the I7- year -old who does not drinkmay be considered a problem by some of his fellow teen- agars.

The Problem DrinkersRealistically, the problem trinkets ate those who-----by all standards

cause sig,ithaant damage to themsehes, their families or their «immunitiesbecause of chinking.

Nome ale (lead). :ntdictive ihinkeis or alcoholics. in addition, the list ofexcessive or pioldcni diinkeis ;mist include [now who ate *patently notaddicted to alcohol, who sly INV no symptoms of dependent y. lint whosechinking has nonetheless created setion% puiscmal or family pmblems.

An example inay be the non typo had always been a light thinker oreven an abstainer, who kid maintained sitting family ties and a good jobleconl and may neve] hose been mole than slightly inebriated. But on oneoccasion he took too many chinks, got into his car and smashed it into a

785 70 - 81

16

crowded bus. Such an individual could not properly be classified as analcoholic; nevertheless, he has to be considered to have been a problemdrinker at that time.

Among excessive drinkers of various types and degrees, most interest hascentered on the addictive drinker- -the alcoholic. It is ftequently thoughtthat alcoholics can be specifically defined, diagnosed and counted, Unfor-tunately, the situation is 001 that simple.

Alcoholics: DefinitionThere is at present no folmal definition of alcoholism or of an alcoholic

which is universally or es en widely accepted. Perhaps the one most widelyconsidered as authoritative is that by Mark Keller of the Center of AlcoholStudies at Rutgers University, which follows closely that of the WorldHealth Organisation,

"Alcoholism is a chronic disease, or disorder of behavior, characterisedby the repeated di inking of alcoholic beverages to an extent that exseeds customary dietary use or ordimacy compliance with the socialdrinajng customs of the community, and which interkres with thedrinker's health, inter-personal relations or economic functioning." 64

Another impoitant concept. described by Dr. Ebbe Curtis Hoff of theMedical College of Virginia, is bastal on three facets: (1) There is loss ofcontrol of alcohol intake the victim finds himself drinking when he intends not to drink, or chinking more than he has planned. (2) There isfunctional or structural damage--physiological, psychological, domestic,economic or social. (3) Alcohol is wed as a kind of universal therapy, as apsychopharmacologkal substance through which the problem drinker at-tempts to keep his life front disitacgiating.57'

These definitions and others that differ from them only in minor degreedo not specify any habitat of the alcoholic; they do not mention any factorsof poserty or degradation; they do not mention any particular beverage;and they do not involve the quant;ty of beverage consumed in any givenpeeiod. All refer in common to a destructive r, j on alcohol.

Modern concepts of alcoholism no longer attempt to set rigid boundariesbetween the moderate thinker and the alcoholic. Most professionals con-reined now agree that !hue is 110 cxacI point applicable to everyone, belowwhich one can accurately state: "This man is not an alcoholic and cancontinue to drink safely." nor above which one can state: "This man isnow an alcoholic and can newt contiol his drinking."

Disease or Self-Indulgence?Problems of definition have a'0 been involved in determining whether

alcoholism should be nested as ;1 disease, a symptom of immorality, aweakness or self-indulgent e.

In RI56, in an unprecedented action by a motor group in organised meattine, the Ametican Medical Association deci .ed by a formal some of itsHouse of Delegates that "alwholisin must be tegarded as within the put-slew of medical practice." 2 '1 his most-, later suppotied by ether medicaland hospital gtocips. has been (Rllied with dramatically altering the posi-tion of the alcoholic. Because of it, neatment has been souOt by many.

6 17

alcoholics who otherwise would have remained hidden, as untreatable vic-tims of an irresponsible craving."

Two conic rulings during the early part of 1156 have further supportedthe view that alcoholism is a medical prolam. The United States Court ofAppeals for the Fourth Citeuit ovintutned the public drunImmess convic-tion of a North Carolina man on the grounds that i: was uhconstituticnalto punish a person for acts he could not contuoLY Similarly, the ll.S. Courtof Appeals for the District of Columbia ruled that chronic alcoholism isnot a crime.37

"flue District of Columbia tiding held that proof of chronic alcoholism isa defense against a drunkenness charge bet ause the defendant has lost thepower of self-control in the use of intoxicating beverages."

Nlany people do feel that the alcoholic may be no more responsible forhis drinking than, for instance, a tuberculosis patient is responsible for hiscoughing. They believe, however, that such patients must he brought tounderstand that they have a moral responsibility to seek treatment and tomake all possible efforts to help themselves.

'1 his attitucie is, however, far hoar universal. There are those who stillinsist that the "disease" concept merely p:ovides the alcoholic. with a com-forting alibi, and he can timeline (Jahn dr,t since he is sick he has noresponsibility for his continued drinking.% 1'27

The Habitat of Alcoholics:The Skid Row Myth

A firmly entrencfed klief in some quarters is that roost if not all alco-holics are on Skid Rowthe most dilapidated section of almost every largecommunityand that most if not ;di skid Row inhabitants ;Jr? alcoholics.As a consequence, it has been thought that eradicating Skid Rows woulderadicate alcoholi.mi, and that the end of alcoholism would mean the endof Skid Rows.

But investigation has shown that many people on Skid Row are not :ricoholies or even heavy drinkers." i2 A e_hicago study found that the majorityof the so-calked Skid Row limns could not be classified as excessive drink-:107 A New Volk study showed Ono fewer than 15 percent of the Men Onthe Bov.cry were alioholio nn :1. than 55 permit were moderate ornon- chinkcrs.rso

From runner r ,-search, it is 'disjoin that most excessive drinkers are notSkid Row derelicts, :19IC than 71) pkTh'Ilt Of them reside in respect-able neighborhoods, live with their husbands Of try to send theirchildren to college, belong to the commy dab, attend church, pay tans,and continue to pet fonu mine or less elle( tiveiv as hank presidents, house-wives, farmers, salesmen. machinists, stenogiaphers, teachers, clergymenand pitsicians.A

1 he ()PO of bt ti age consumed on Skid Row are most frequently a lowcost dessert wine in the United Si a (077 a low -cost table wine in France,119a rialive: 'whiskey (t ac hay) in ISrvil,tu and a iowqcq von" in Russia,Pol:nul, Slc(1(11 Finland.2" 112

'lime is no esitichce to show that any one of these beverages is, in itself,the (Bleu cause of excessive drinking or alcoholism, or Ow alcoholics are

18 7

addicted to any one part+colar beverage, Instead, it is believed that alco-holics are addicted tophysically or psychologically dependent onalcohol.If one beverage is unavailable, they will usually turn to another.131

Consumption by Alcoholics:The "Safe-Level" Myth

In the United States and Europe, attempts have been made to establisha "safe level" of drinking -the amount of distilled spirits, wine or beetthat cart be consumed daily without danger. In France, such attempts haveled to the widely publicized admonition of "no mole than a liter of wineper day." But researchers have found that many alcoholics consume on theaverage less than the equivalent of a liter of wine a day, while some socialdrinkers consume more.119

Expel is have concluded that how much one drinks may be far less impor-tant than when he drinks, how he chinks and why he drinks,

19

8

III. EXCESSIVE DRINKING:SCOPE OF THE 131()131,E NI

-ho those who ',clime ill abstinence, an) chinking of an) alcoholic bever-ages ill any amount is cx(sske dlinking.'ho the niajmity, however, 'nob-Icin drinking occurs when aii)one chinks to such an excess that his abilityto control his oc (ions ;aid maintain a socially acceptable life adjustment isintroit ed

-111c ement of this kind of chinking hos been expiessed in terms of thenumber of people tialfic occidcnts. imuipowel losses, jii)cnilcclelinqueney. deaths alal financial 1,111111 ns to cue cormitinit). Vhilc such

have been Ividcl) a«ehte.1 as scientific hut, roost of [hese measure-ments arc or.1) 1011g11 estimates. 1:111 (X;11P pie, alcoholism 11;11 hcon Irecittentl) cited as the louith-ranking public health l»obie,c) in America,surpassed orals heal! discasc, cancer and mental disease. I hew is, how-ccr, no )1(cincci lankiug, of diseases as -public health poblents. if sucha listing could prepared. it is not known whether alcoholism would heploperl) ranked fourth -0r second, tenth or twentieth.

')er of 1)riiikersThe number of ,1,1»cticans who use ;11(01mlic beverages is not kno1))1

exactly. Estimates suggest that the pc rcontage has been increasing steadilyfor at least a (entur). .\ 110,5 nationwide )ati)ey 31 by the Social ResearchGiocii) of George niictsit). which was based on a 'weighteds,m1hle of _2. Iii subjects, indicated that 1,8 percent of all .1'11(11c:in adults

porccin of the men and lift 10 :cut of the womenchink at least occa-sionally. And, while the 1401,011ton ))1 ntce Blinkers ill the adult popula-tion has lemained about «nistmo ill the imst 2(1 teals, the pfopoition ofmaomen (trinkets has iiscn.

Out Of all adults, the solve) classcd 5fi pc.1(( tit as infitqucill to moderatedi ink( is and 12 1)(1(( ni as lien (linker). lard ate not ne(cssaiiI)aliolioliis hot tint (Ill ill( hale the plohltin di Mkt.'s. 1 In') ate mote alit tobe men than women (at a ratio ()I four to mu) and «impaled 10 abstain-ers and moderate chink( is- ale osuall., )mii,'2,er and )vealthicr, eniettainmole, go to (11111(11 less, and twill (loser with fellow notkeisOran slid) ileighbois,

.1 191(t sin 5cy `,", 10)1101 that the ptopoi lion of those )v11.) chink was

highest in the .11.111111 Mill NOV I'llg1.111(1 tilates :I1111 IlMCSI ill theSOl11.11 (cutlet titans, highest .00011)4 'Avis(' under the age of '..19 and lowestamong [hose 1,5(1 the age 01 (10, highest among Jews and Catholics andlowest among Baptists in g(11(1.kl, tlic pi opollion of !how who w:)).

highest aniong lcsidcnis of and those \yid) hipheiinmme and 0( atiomil stale.. 1)i inking was 11)1)11 tell I>) 711 oct«mt

20 !I

of those who were single, 72 percent of those who were married, 69 percentof those who were divorced, and 51 percent of those '.ho were widowed,For the widows and widoets, the low percentages ma,: have been more 1reflection of age than of marital stank.

The Number of Problem DrinkersBecause of such problems as poor health or marital troubles attributed

to drinking by the drinkers themselves, by their enaidoy'rs or by the police,ten percent of the (trinkets studied in the 196'3 survey could be categorizedas problem drinkers.

The percentage of problem ;trinkets by this definition was highest in theWestern part of the United States, and among males, residents of the largercities, the divorced or Hamm-lied, those with the least and those with themost education, and those with the lowest and those wilt the highest vocational status. The lowest tates were found among Lutherans, Congregation-alists, Presbyterians, Episcopalians, and sews.

The findings from this surrey suggest that the drinker in a group inwhich chinking is less prevalent may be the most likely t) encounter troublebecause of his drinking.

The Number of AlcoholicsEstimates of the number of alcoholics in the United States are among

the most publieindand challengedof statistics on aLoholism. Accordingto the Rutgers Center of ,Alt ohol Studies, the number may be between fourmillion and use millic approximately four percent of the total adultpopnlation.38

Temperance groups and many alcoholics and their friends and relativeshave (tainted the figure is on low, Others have declared that it is too [nigh.Actually, the number of alcoholics is unknown.

Much of the confusion on this subje, t has stemmed from misapplicationsand remarkably divease interpretation; of the "jellinek (ormula,- developeddining the 1910's by the late Dr. E M. jellinek of l'ad.s. This method usesthe total number of d aths how diagnose(' cirrhosis of the liver as a basisfor estimating the number oi ahofmlics in an area. Statisticians state thattLe formula is not icliable.3'105 d.:0 and jellinek himself recommended in1959 that it no longer be useddf

Sex DifTerenceAUntil the 1951t's, it was estimated that there were be or six male alco

holins in the United Stales for eve ly female alwholk. hl the 1960's, theestimated ratio had lepoiled1) (hopped to font to one, or even loer.D 29

Many studeins of the piobleni litive suggested that the inclease in thenumber of female aleoholks noted dining mem ycaii is ptiminily dime tothe glowing willingness of smh women to seek Iteatircit and new, therefore, be mme apparent than real.r.

Regional Alcoholism RitesProminence gisen to apparent diticienecs in the icicu fed lairs of alco-

holism in minus eities and States has pteseiked inn( f legional embarrass.mend 10 ',tide, but the comp,oisons ate not believed ',u be reliable.

10 21

Since these estimates are usual!) based on the jellinek lormula, usingrates of diagnosed tit rhosis of the 11511 its determined at autopsy, the figuresin many instames may reffeit not dillel..-n(cs ill alcoholism but differencesin the mantle] of detecting or repotting eh thotisf"

Risk of AlcoholismThe only absolute instnaine aaiost alcoholism or problem drinking is

lifelong abstinence, The risk of number of alcoholics asrelated to tilt number of people who drink---,annot be stated with suchcertainty. If the number of adult drinkers in the United States is assumedto be about 80,000,000, aml the number of alcoholics assioned to be1,500,000, the tisk rate among (Milkers in this ((inny would ,appear to beapproximately 5.h percent, or one in 1S.

There is no support lot sn(h publicised assellions as -on: out of everytell drinkers -or -011(.. out ui esti y is inny fated to become analcoholic.

'Trends in Alcoholism Rates.%.lthcLigh it is frequently &limed that the rah' t alcoholism in this

counti, is inotinting tapiify, there is Ito itific ,idence !alaithis is so, In general, the data an so incomplete, the methods of diagnosingand repotting in different (immunities and pores ional giuups o differ-ent. and the inteitneiations so iontroseisial. that it is impo,sible to deter-mine today if the late of alwitolisin is in< 1 cdsing, iletruvsii4,, orsteady.

.1 'emit stoat, .011)111)101 hy the National liotitute of Mental Health511(itS S, Plottever, ;I: Itll IC;Psr ilt the 1-,it (If ;tdali,;ions of ;tieoliolio

55it11 tie mo,..1 severe bonus of the dis:tase -to State mental hospi-tals. Fiorliti2,s ieyeal that imp in seven newly ad lined patients in such insti-tutions is an an '8 puit ( r cais, lit nine States, ako-holism le:11, all single cliai.oloscs mental hospitals.

.1t the cone time. the monbel thin( s beds in genet:II hospitalsma, .1«i11o1iis has initeand b as t Itch as 50 patent in some

11(15 doting the past less. . \l.o. the tis in the iittnibei of alcoholicslet cis ing ticatinclit in both !midi( and ink ate hospitals and (links is 1)1°-1)l )16mi:oily gtuotut th;Iti the in the population. SolncillVtstiL.,:itOls 10111111(11 111;11 till rise in the 111:1111)11 of alcoholics in Statemental hospitals probably tellei Is a true it (tease in itkoholisin late: ill theNation its a Ys hole. Others sil2,,gesi the icpoitcd iise is the result of Change.ill aissifoation jinn orioles ;old in hospital :t(ll litsyion

Alcoholism 1)caths,1(«1 ling to the latest nalional figioes (for 191;1)1

alcoholic (Mhos,. and ,diilholi pssilnisis all )tinted tot about 11.8 peoentof all 1catlr.1+7

Some authl,riti,s -ion oil that th. pen illlage i I It 1110 1)155. t1I;10111)(

(111): ;LI(01101 di( 1.1111 OM), 10 111;111 dead s 55 1111 It ate atrtibutcd

to (1111(1 C.tistA. S(0111t. ph'sili,Ills LIR Hid pitting ;11t 1)11011%111 till the (11',11h

lifl<H111: 11111 if c11111r1, 155 lilt' still Ins Of Ili( thLt'Ll.,(11.

Some estimates base indicated that the life expectancy of alcoholics isapproximately 10 to 12 sears less than tile aver,ige.51

Traffic AccidentsThe National Safety Council has teptated that traffic accidents in 1965

took 19,000 lives, caned 1,500,001 disabling injuries and cost about 58.9billion in property clittnage, wag.: losses, medical expenses and OVerliendcosts of instira»ce.99

Alcohol has unquestionabls. [dosed a tole in this tragic toll. Here theproblem concons ric0 only alto! (flits but also non-addicted individualswho have had too intuit to drink.

The Public Health Sersice's :II:filly Control Program estimates thatakohoi contributes to or is associa.cd with 50 percent of fatal motor vehicleaccidents.

Recent tc.scatch. conducted with the use Of ;11C01101 tests on blood, breathor urine, has deinonstiated that ti is estimate may be too low.101 For exam-ple, studies in New Yolk, Ohio. 11oot,tna, Atifona, Delaware, Alatyland,New Jersey and Contiecthut have indicated that 17 to 87 percent of thedrivers in fatal ,ucidents had beelt drinking. .\ 1959 investigation in NewYork shoti.ecl that 75 percent of such (hive's had blood-alcohol levels ofmore than 0.10 ifeuciii 0.10 grains of alwhol pet 1011 tc of blood.99

scar-long California study in 11162 banal that 02 percent of the driversand .10 penent of the pcilestiLins tt fatal a«idents had been chinking: and53 percent id the chiscis and 3: pc.i«lit of the pedestrians had blood-alcohol levels of more 0.10.10,

Statistics bout a pie:imitialy st ids by Indiana Unisetsitys 1)epaitinentof Police Administiation show di, t the woist chunk-dtititig records belongto men lic.tsvcc it the ages of 21 ;in 1 I I. inct and women who are widowed,separated in dismced, and those V hill CI' ;111; bccluetuly or 113N I.' a recognitedchinking 1)101)1C711. In iollIlast. ' 1VolI 1/11k-ii ttident rccnids Inc IOWAaltlertlg wuntt,, 111(11 'dirt women '010 are single, and those who think onlyarum( once. a month, I the hate ti high accidentrate. but 7t1( 011111 s tatels intnlsccl in then a«identsas

Ffloits to tediae chising while under du. influence of alcohol imludcimpimed ixtblit cdii,ation 1,1t):2* 7,1. '.1,ill)i017111111 iii unifcm» ...State lawsV.1101 NVoUlit gise piitice the is determine III,Ald-al(edlOI levels of anysuspii 'hist 1, odiiititm of di,. fit ii Isle! of intoxication to (ili)peisc.ait ;Is it is III 111110r,111 tOtIllilit's; and, piticulatly.mote sit my law enlist., nic lit.

Pnhliu attitude Ins been ',idled the gicatest obstacle to a SII(on the it itkirig'slid. I hr 111Ni:6,6,4:0W, trprnt III:0 ill]111(1 ale (1,1111Inr," d tnlitcls of tend to identifs thenisulscs witLthe di lenclant unkidi is Mg a .(s. ;1111I to svntpathiir 1601 his plightpattii Halls as he i.10 it appeal , at the nail as ;I sobt.1 .l1,1

Itlit II,."II is csiduo, of siilhrlcs, Ili ii (1111/1«111( :done 4;111110I Ai- a tune

piste SrlI()11 io 1110 111Irl( ill of chitin' ulrilr under the influent': of alco-hol. (hie ol the 11140s1 rigid ,me.' IIiiticu 11 enIoucinuu plog1,1101, Ii.n brat

i1 2

9

ap,,lied in Sweden for nuitt }cans, and <<t the chinking-driving problemthere has remained serioric.4

'Ile Cost to Indtcin,American inclusti gencJally relused to tecognire any "problem with

alcohol" until the late 10 In's. Until that time, many employees judged tobe alcoholic were smomarily flied. not this quick and simple solutionsolved nothing lot the employe, nothing for the community, and very

little for the company. liy the 1961fs, the attitude in some inclustr;a1 organ -:rationsthough by no means in all of thenehad undergone a markedchange, and there was glowing recognition of the costs of alcoholism tobusiness and inclusoy. 'I hose costs are estimated note to be S2 billion peryear, and the problem has been labeled "inthistty's S2 billion hangover."

This estimate was deseloped by the National Council on Arcoholism,11 1in coopetation with ,1 number of typical .11nel icatt firms. It is based on anassumption that, as of 19'6, (I) about duce peicent. or 1,700,000 of an

business and gioci 1111101f \Volk forte of 55 million were alco-holics; (2) their :15u1;igc suit :Willa 55,000; and (3) each alcoholic'slost to his company for I tst manpower, inulkiency, leplaceimalts, 'tingebencfus and incested training expense, tea, a minimum of one-fouttli ofhis salary, of SI,250 a seat,

-- impossible to determine accurately may include fric-tion with co-wollsets, lowtred moiale, bad executive decisions, ?Ind deteri-orated customer and porli,it relations, I miucstionably excessive drinkingresults in the loss of tioined and expelicnced employes. This last factortan be especialk damagirg, to :1 «tiiipony, since alcoholic employees areusually in their middle scars NVilli many ciiis of service. Such (Apt:1101CMNvoi kepi MA' iiii.ong the most calttalde assets of any flint.

Alcohol and Ci hoc

bunr is ofointlant ttstimon ihoholism and tidier fo,nis oftiNicssic chinking ssiilt MICAS Inc tri111e.

Of a natiumvidt. "(HA ()! 1,97701 1 7 ;tilcsts lisle(' for I065 by the FedetalRnlcau of Incestigolion, ;drum 15 percent, were for olIctiscsof chniikenness public intoxication. disoulcaly tooduct and sagiancy."'

he «ist to .\rucitia's toxycyci, tot the :mot, tiLd and mainttoonte injails 01 these esocsske ittlilfu'is has lleen csii:11:11C(1 to be nl,un inilliOlis ofdoll:11s a yxtr.

.Sociologist, hose noted that the attests lot di tinketittess ptobobly invokeonly hi iclatisely small to, 1111(1 of a «mitiniiiit's extessile drinkers, mosiiySkid RIOW illit;11)Irillts who ',Ill' ;113C51 'leased amt illiCS1C11

11111 C' alter Ileis is tee +u 1,111c11I (1118)1" \%111(11

pres,lll, In 111()S1 (1,11111tunitic,.1(=`y1 Volk (;its steins to lie Ti. CMCI)11011, tlitr citilS

of :Olcsis to inli Sit III. I hi timittestionobk ieflccts not a low,1 diltcnut pluilos juhs towdid the 111111c111,

and gic.itt adilt 1,111 1,1 .1 jufici,d ruling in 19.;(1 that ;mods arid jiltshould 12(11 be 'I'll' Ill (4,1111t,t, 11 1141 is .1 11111114 11101111 ptobltm, ,7

2411

Additional investigation is needed to clarify die significance of alcoliol inmore serious clinics. Police records indicate that alcohol is often involvedin homicide, assault, offenses against 5 !circa', and theft, but to what. externhas not been established. .\ recent Califmnia study of more than 2,000felons concluded that "problem drinkers wet more likely to get in troublewith the law hecaose of their behavior while chinking or because theyneeded money to continue drinking." 2t

Alcohol and Brain DamageThere is no evidence that niodelate consumption of alcohol 11:6 ac, appre-

ciable effect on the pelmanent stincime or function of the brain or othernerve tissues. llossever, brain damage has been observed in those who chinkexcessively for many )erns. This has been atnilniacci to a deficiency ofvitamins, ptoteins and other essential mulleins:29 In many cases of mentaldisease among alcoholics. the eaw,e may be act underlying psychosis or otheremotional :ondition which contributes both 10 the abnormal behavior midthe excessive chinking.

Alcohol and Family ProblemsAmong the most destiurtive cflelts chiaged against excessive drinking arc

unhappy marriages, broken homes. descition. disoice, iinpovelished fami-lies and deptised or displaced childtcn. The cost to public and privateagencies for suppott of families ravaged by alcoholism has been put at11120% millions Of dollars ,1 year. lily: (051 in human sulfering is incalculable.

It should, however, be understood that when ex, essive drinking is iyoked in these social cacistioplies. it may not necessarily be i.he inimarycause. In many broken man iages. the complaint is heat& "Everything Illsall right until my husband smiled diinking too much." licit pen eptis emaniage rounsclors hase asked: ''If 5:v(1'1E11111g Was all tight. then why didhe shot chinking too nun It

It is cleat th.it not unit does the alcciliolic allect his family: the familyalso ;11fects the alcoholic- and the severity of his illness. Solutions to suchtahgled telationships usually pose in ohlguis that can he resolsed only if thebiolog. al, psycnological ,cral sociological aspects of the specific situationsare placed Ill balance for each member of the Lundy.

'Teenage I)rinkingAdult (11111(111 about case of :51«)11,)1 It ).4)1111,4 pt.ophe in the ('Wiled

States dining 1 Clellt teals h:lt 101.11 d10111:11 I 1 1111,011t loyal 11 the tlIppoted

Idat1011t1111) 01 juvenile to Illtellih! (10'1111(11101r t'k,(011111t 01

riots 1111(11 ;111S011101111C ;,11 1(1(.11 It. Atnihrued 111 I et Ill III r)t to teenagechinking. ate SO A.011111114 to 100s1 adults 01;0 tits siuletue Of these ettIlei01.1.C11 01)51 utcs the fat t..s7 1='

MUCh affentI01/ hat 1/111/ hat 115e0 in) the f,ctecntnge 0.1 1:11/.1,14(IS who

drink, au l the age at which they lust caste al«sholic bcaciages. Sin scys inch.<inc that the aica,tge Alm hitt 105(1 ,,I,111101 -00;111) 111 ...1.10 101111 of

all e79)(11111(11L11 tip by the age cd Itl. As mans as 50 to Ki patentof high school sticdents, depending 1111 the all, saS !! ey (1.1 ink al least0(1 aSilln:111S,

14 21)

"'nese figures, however, as shocking as they may seem, are meaninglessin th,inselves," say, 1)r. Robert Strait., of the University of Kentucky."There is no proof to show that early exposure to alcohol will in itself leadto cscessive drinking in later life. In fact, all the proof is clearly to thecontrary."

Although a teenager who drinks is frequently assumed to be a delin-quent, it recent NIass:ielnisetts investigation 11 showed that the percentageof alcohol tiset..!. is about the same among delinquents as among normal highschool students. The chief difference, the study concluded, is not how ni:Alyof each group think but how they drink.

Research shows that t«.nagers follow adult models in their drinking pat-wins, and the best single indicator of the teenage drinking pattern in ;-.11ysp«ific community is the adult pattern in the same community. If parents:kink, there is ;, high probability that teenagers will Wink; similarly, ab-stinent patents typically produce :tbstinent children.

For both adults and teenagers. drinking patterns vary with sex, Soiioeconomic- status, religion, ethnic backgrotincl, rural or urban residence, andother factors.

These findings are based on use studies involving 8,000 high-541mol stn.ticrus \chili:. the last ten vca 'it live areas of the United States: NassauCounty, New Volk; 1istonsitu Nlichigan, Utah ;int/ 1:ansas."f1 .\ stimittatyof additional findings shows:

1. he avemge age at Itllieu students had their first chink is Li-1.1. al.though they ,1:iy have "tasted" alcohol beime.

2. First exposuic is likely to be it home with parents.Practically mu") higluschool giacluate wilt have experimented with at

least one think.I. One in film users cl,iiutcd ut f1.1Vt. 1)1,111 "high" it least once ditihn,

the month ptior to the II:SI:Moll, in the Nevy Volk, NVistonsin anti K.ansrs,

5. (hie in ten u cis in these studies repotted hating been "drunk" inthis saute period.

6. In all 'lie studies, beet )was the most ,cmintotily used beyeiage.7. Laws relating to teenage thinking train little it lationship inki114

irtic es.The rate of inob!tati thinking among teenagers is ;I/patently tatted tr

affinities tost-ald Winkitty Fin cs,Imple. tr.-ea/tic has tcyvalcd thiltheain Itali.m.1intaican Aid )L-Ijs11 1..1111ilit's 111 :lit- CiSpost(1 IL) L0,41114111 at .1

set smilclilitcs .1s Lrl111,..; as Itycl to dill' uals brit ti,utr 111) tobays the Inwcst taws of Alt rLIILdislil of ;in gioips in the l'nitc.ltil:i 13).. cunh.isl, ',Mile of the fligltusf altolio! addiction 11.1)c beenfound .ill groups in %L'Ilit 11 t l[iitIt'l suoug pressure to It'll.1 i:1

fruut clinking until dies ale 21.7 '"Robeit Schlt.11 1). 13.1M11, in flash studies of coilege

in:4.N hate attempted Iri cIL HILL. 111C tt'1,11iLlIship

thilkhug and the (Num to which students Income intoxicated. III the.1.investigation, «ot,iilig «dleges ;Ind 17.0011 students. they totmd lhatdress colleges with the bottts, !Act midge of thinking stitthans acre genei

IS

ally marked by the highest percentage of students tcho had ices intoxi-cated. By contrast, excessive drinking was supottedly infrequent in thJsecolleges where student drinking teas most

The college study also found that those students NVII0 violate the accepteddrinking customs of their families are apt to go (nailer in their thinkingthan do students for whom thinking is acceptable behavior. Thus, itmongthe relatively few Mormon students who drank, .12 percent of the malesand 11 percent of the females repotted the ocitirterce of "social complica-tions" as a result, while such problems were desclibed by only 20 percentof the males and 2 percent of the females among the many Jewish studentswho chink.

In summary', ;ming person's decision to think or not to drink is usually.made on the basis of a tomplex of fortes int haling the prattices and wishesof his patents, the attitudes of his rhumb, the influence of his peers, howmuch money he has to Tend, and how strrAtgly he may be impelled toassert his independence f.'om authority.

"Fite majority o' teenagers scent to hose tasted nkohoi on more than oneo«asion. Few of them hale !canted much in their own homes 7tholt its

16

TIIE CI-IEMICAI, COMPOSITIONOF ALCOHOLIC BEVERAGES

In all the major alcoholic beverages- -heels, table wines, cocktail or des-sert wines, liquents 01 cordials, anti distilled spirits - -the chief ingredient isidentical: ethyl alcohol, knolvn also as ethanol or simply as alcohol. Thecomentratior 's usually about 4 percent by volume in beers, i2 percentin table wines. 20 percent in cocktail Or dessert wines, 22 to 50 percent inliquents and 10 to 50 percent (Hi) to 100 profit) in distilled spirits.

In addition, these beverages contain a variety of other chemical constitu-ents. Some come front the otiginal grains, Mapes or other fruit::. Others arepioduced during the chemical proCesses of feamentation or during distilla-tion 01 storage. Others may be added as /halo/ il/f.4 ur tutoring.

Modern intestigations !lase shoevii that mans of these non- alcoholic sub-stances do mole than contlibute to (0101, liasor, aroma or palatability.Some may have ;t diva( eilett on the body in thcauselscs. Others appaictitlyaffect the rate at whiell alcohol is alisolbed inn> the blood and the rare atwhich it is oxidised or metaboliied in the tissues.%0

the critical factor in analyiing the elle( ts of chinking is not the amountof alcohol winch is drunk in which leaches the sioniatli, but the amounttcioicll enteis nit blooiltneani ;Ind the speed lit whiell it is inctalroliced.4 7"Only after the altohol has been absorbed [loin the digestise nact into theblood and taiiied io the brain and ether tissues do its most importantphysiological and psyi hologit ellet is be«mie

Studies It slir ! institutions as Yale. 111itelsity,70 "r, Stanford l'iliser-sits,10.: I" the 11/S11(111C of N111111/011 in ROM(' %" :toil the hatolinska Instituteiu Stockholm hate demonstiated [hat beers, wines and distilled si hitsmat t al, 111:11kt11), it1 tilt talc at Itil lhi the alcohol 1het «it:tin is ab-solbed into the Mood. Ito genetal. the highei the cou«ntiation of the ;deo-

the mine Lipid is its alisoiption, and the highel the itaticcornititin ofnonahoholit (1)11111(10nts, Ole sl(155u1 its Absoiplioll.

he -Congeners"he use of the tun] ''congeners" - one lime the mime for the ramous

nnlr(litti ait01101 S111),1.1111 es in almholi best ta;.;cs has °fun beenStilt dl }' defined. "congetivi- -of the tame kind,- and 111115 W0111(1

scent it> :11/111) 0111) 1st sill 11 odic alcohols as methyl, plopyl and isopiopyl.Ixttiagts as hut!, ,1141 %VIM'S also titiliain

;ildelodet. ketom (sit is, rim( nil., salts, sugals, antibm [(aril compounds.amino ;acids antl Sit,nnim. %%kith ate rIeatlt not .11(.111015 but ale nolichlic-

ss oh( 11 (;1111 (1 cotigunt Is.

11 lit. notion Aral all "tilm,( mi." 11111tu.iltli 1'1 Of ht 1 wkc nncle-

sit,rblc is 511)1 C SO1111' 111 the 1,().:111 101,1)1.i ..111)st,j)j, s sic it as !ht.s a l t s , 511,4,11 5, 11610 :it kis and S1(.1111110. .11 t 111.1f11114111.111) 11,0111.

2 17

The Fusel OilsCertain of these components of alcoholic beveragesespecially some of

the higher alcohols known as fusel oilsare relatively more toxic thanethyl alcohol. But these usually occur in such low concentrations that theypose no clinically significant Itazard.;0

Contrary to the popular belief that fusel oils occur primarily in new,raw, or Imaged whiskey, and similar spirits, and cause most of the objec-tionable taste and aroma of SITCh beverages, chemical analysis has shownthat their concentration actually increases with aging.72

The Value of Chemical DataThe rapidly growing knowledge of the chemical composition of the

various alcoholic beverages has obvious importance to the hes erage indus-try in controlling the taste, aroma and appearance of its products. It alsohas value to scientists engaged in investigating allergic reactions to thesebeverages, their effects, clinical applications and hazards.

29

IR

V. EFFECTS OF ALCOHOLIC BEVERAGESON THE BOI)Y

it was long believed that the actions of beer, ;vine and distilled soiritson the body and the mind could be ineasered simply in terms of thequantity of alcohol consumed. As a result, much of the classical laboratoryresearch in this field was conducted with pure alcohol. It has now beendemonstrated that the situation is far mcne 1001plcx and that many of thefindings made with plain alcohol solutions do not necessarily apply toalcoholic be,Trages.

Further, it has been shown that the effccts produced by alcohol takenon an empty stomach are far different front those produced by the sameamount of alcohol taken with food. The effects on a light drinker arceisually different hour those on a heavy drinker. Also, the effects producedby the Sallie ;:inount of alcohol may differ from individual to individual,and even in the same individual from month to month or limn day to day.

AbsorptionUnder ordinary conditions, the :Aeolic] in any beverage is absorbed

relatively quicklysome tiotigh the stomach, but most through the smallintestineand then distributed generally throughout the body. The ab-sorption can be markedly influenced by a number of factors:0 45"

I. Alcohol concentration. The g -eater the alcohol comenuation of thebeveragetip to a maximum of about 40 percent (80 proof) - -the morerapidly the alcohol is absorbed and the higher ate the lesulting peakblood-alcohol comentiations. Iith identical ;lino:nits of alcohol swallowed,the highest bloodaleohol levels arc plodueed by to distilled spirits,and the lowest by beets,

2. Other rhemneds bvcrogc. The greater the amount of non-alcoholic hem ic als in the bey claw', (Ili: more slowly the alcohol is absoil-..d.For this 'casein, too. the ;Ileolied in distilled spilitsespecially vodka toldgin--is absorbed most rapidly, and that in table wines and heels mostslowly.

3. Prrsene of food in the' sfoonarh. Eating with di inking has a notableeficet on the absoiption of alcohol. ('specially when ahohol is «mstimedin the form of distitIcel spirits 01 wine. ISlite rt ;dwindle lieseiages ;tie takenwith a substantial meal. peak blood-id; ohol «meciitictions may be :educedby as mode as !lin permit.

4. Speed of drinking. 'I tic 111011. rapidly the beverage is ingcse'nl, thehigher will he peak blood.aheiliol winentrations. hus, these Joel,

lower when the bevei.5 is sipped 01 'en in divided amounts thanwhen it is gulped or Liken to a single dose.

5. Enopt)ing ti505' of the ,,o,Plrld,. lit ;1 tionifecr of e hoical conditions, %nth

30 19

as that marked by the "clumping syncitome," die stomach empties morerapidly than is normal, and alcohol seems to be absorbed more quickly.Emptying time may be either slowed or speeded by fear, anger, stress,nausea, and the condition of die stomach tissues.

6. Body iticiglit. 'I he greater the body weight of ac individual, the lowerwill be the blood-alcohol concentration resultimi, from ingestion of astandard amount of alcohol. The blood-alcohol level produced in a 18f1-

pound ut,m consuming four ounces of distilled spirits, for example, willgenerally be substantially hewer than that occutring when the sa ue atnotintis taken by a I 30-pound man in the same length of time.

MetabolismOnce absorbed and distiibuted by the blood, the alcohol undergoes

metabolic or oxidative changes. A major part of these processes occursin the liver. alcohol is changed lust into acetaldehyde, a highly irritat-ing. toxic- chemical, but this rarely accumulates and is oxidized quicklyto acetate.

the acetatethe saute as that produced as an intermediate in sugarnietabolismis !rims/brined into ;t voices of other compounds. andesentnally is oxidized completely to carbon dioxide and water:12 The totalmetabolic process yields apploximately seven talories of energy for eachgrain of alcohol.

Research has demonstrated that the tate of alcohol metabolism, likethat of alcohol absorption, inay be influenced by a number of factors. ANlassachusetis Geneial Hospital study has shown that both alcoholic amtnonalcoholic subjects maintained on good diets can moderately increasetheir- late of alcohol tiletabi/isill if they consume substantial amounts overa long period of time. In general, it appeals that die rate of alcoholmetabolism may have a small influence on behaviotal tolerance to alcohol,but that no significant differences in ability to oxidize alcohol differentiatethe alcoholic- from the nonalcoholic.91 ,\t tin- Katolinska Institute inStockholm. it has been repotted that normal drinkers can metabolize onthe average lititroxiiniitely seven giants pet limn of puce alcohol: eightgiants in the font, of tvhiskey: nine grants in the fowl of dessert wine:nvelse grants in the fonn 1 tableo. si..nes: and nine to ulevetr pants inthe fourt of becr.49

Considerable ellott has been (looted to a seault for some method whichtonic! clfccti els speed the rate of alcohol metabolism and dins be usefulin the Ileatlflent nl into\ Paid( Oat lilleteSt has !Kan eXpieSsedin the administration of uniting tiiiodothisionine and other agents, al-though none has yet been !mind to make any clinically significant differ-ence in the late of ahohol metabolisnit-`

ExcretionAlthough must nl the ;alcohol is 111(1.11)01i/ed. (will Mut lc fist'

liliterit is eV (hunk Jilt halitted. 1114),11 in urine, hleallt andslVeat.

St int tilant cat Depressa nt?

yy Ulf most oda. all\ at tits chemicals the genet al pftssio/logic. al dice is of .1/(11101 rf ptnd 011 i» tointintotion in the

20 31

specific cells, tissues or organs affected. In most r.ganisns, from the simplestbacteria to the most complex mammals, the cell' lowest concentrations ofalcohol in the cells may stimulate the activity of those cells. In higherconcentrations, it can depress functions, seriously injure cells, or evenkill that

It is impossible to state the specific amounts of alcoltolic beverages thatwill give specific concentrations of alcohol in the blood. In general, it hasbeen found that a 155 -pound moderate drinker rapidly consuming 90.proof whiskey on an empty stomach will probably have a peak blood-alcohol level of 0.05 percent-0.05 grams per 100 cc of bloodwith 3ounces, 0.10 with 6 ounces, 0.20 with 12 ounces and 0.30 with 15 ounces.134

The blood-alcohol level may be slightly higher if the drink is gin orvodka rather than whiskey, or if the drinker weighs much less than 155pounds. The level will be lower if the beverage is beer or wine, if thedrinking is spaced over a proionged period, if the drinker weighs morethan 165 pounds, or if solid foods are eaten at the same time.

These levels have important legal implications. In most parts of theUnited States and in some commies of Europe, an individual is legallypresumed to be sober and in condition to operate a motor vehicle with ablood-alcohol level of 0.05 percent or less, while one with a level of 0.15or more is legally intoxicated or "under the influence.-

Effects on the BrainThe most notable and dramatic effects of alcohol are those on behavior

attributed to t ,e action of alcohol on the brain. 'These :ire related netnecessarily to the amount of alcohol drunk but to the concentration inthe blood. ',ny low blood-alcohol 'evils usually produce mild sedation,relaxation or tranquility. Slightly higher levels, at least in some people.may produce behavioral changes which seem to suggest stilt-dilation ofthe brain garrulousness, aggressiveness, and excessive activitybut which111,!; result from depression of the brain (emus which normally inhibitor restrain such behavior. ,Nt still higher levels, greater dc-oression ofthe brain occurs, producing incoordination. confusion, disolientation,stupor, anesthesia, coma or death.

Due to variations among individuals, it is not possible to gist' the exactconcentrations at which these various changes occur. For most people,however, it is 11511;111y accepted that blood- alcohol lock up to 0.05 percentwill induce some sedation or tranquility; 0.05 to 0,15 may pteAllice lack ofcoordination; at about 0.15 to 0.20, intoxication is obvious; 0.30 or 0.10may produce unconsciousness: and levels of 0.50 or mote may be fatal.

Eat lier incestigatots proposed that these actions of alcohol (vete due todirect effects On tvlesant pacts of the brain- -first the cc telnal coitcx, themost highly deccloped porifoo of the brain, deplessiti, iiti(a! facultiesand .easoning pcsvcos, and producing the lichaciOr 1lattCIJr ch-natictisticof drunkenness. Mid( huger doses, it was helicsed, a' 'iol would directly(iciness sum ssively Iowan levels of the

whichentc,a11) stiiking 11:11

(ClliCIS the SII(11 as the (01IC %chi( controls respiration.Newer observations, howec et, live Icd incestigators to suggest that

alcohol may act front the start upon a regulatory stimuli(' which iotutu modifies the activity of the convey and odic] vitts of the nelsons

3221

swell,. This regulatory structure is the reticular formation, the so-calledmaster switchboard or actisating system of the brain. Even under theinfluence of low bloodalcohol concentrations, it has been found, thereticular formation not only affects brain function but also serves as anintennedirry in producing the sensation of warmth, flushing of the skin,relaxation of muscles, reduction of blood pressure in peripheral vessels,stir s,7ation of gastric secretion and increased peristalsis- -all typical reac-tions to alcohol.63

Effects on Skilled PerformanceIt has not been clearly coablished whether there is a threshold below

which alcohol has no detectable inlInence on refl(x responses, reactiontime and various complex skills. When the blood level reacses 0.03 or0.01 permit, it is generally agieed that changes are evident.t0

At very low bloodaleohol lords, such simple reflex responses as theknee-jerk seem to be more tapid. At levels above 0.03 or 0.01, reflexresponses, reacticsimMie responses ;Ind performances in such activities asautomobile driving and many k; ids of athletics generally change for theworse. Significantly, as a driver's pesformance is impaired, his judgmentoftca deteriorates, and he believes he is driving better. A British investi-gator has found that for motorists the added risk is small and probablynot significant up to about 0.05. above that level, he risk rises sharply.

Effects on the LiverCirrhosis of the liver occurs about eight trues as frequently among

alcoholics as among non-alcoholics. It also crams in non-drinkers. Itscause is the subject of continuing investigation. Cirrlvssis has been reportedto be caused not only by alcohol but also by filtrable viruses, parasites,merexposure to carbon tetrachlmide :Ind other chemicals, excessive inges-tion of sugar and son chinks, and a deficiency of essential nutrients, espe-cially proteins and ceitain vitamins.

Whether cirrhosis can I), produced in tuna by excessive quantities ofair; in combination with an adequate diet tesins uncertain. Manyscientists seem «me fined that adequate Mill in011 pi( VideS an effective pro-tection against cFII ),sis. Sonic semis intestigations, lays-ever, have shownthat huge amounts of ;Moho! lira} cause liter darsage even in well-fedsubjects.58 ii

Effects Olt Other OrgansIn Inoduate quantities. .ilcolro! ;l betesagcs slightly increase the heart

rate, slightly dilate blood VC', k in minis. legs and moderately lowerblood pressure. stimulate :piscine, increase ..he production of gasnic seere-tion, and mask:illy stimulate mine output. The action on the kidneyshas been attlibired to ;iliohors inhibition of a pit duly hormone."

Deficiency Diseasesla :I,: past, alcohol his betri held responsible lot a wide variety of

diseases tsltich tteic uvn (,I(Ull in 11(':n\ (Intact,. 1 hese include "gin-thinket's beam- "beet dtiaet's Matt.- "wintAi slay's stomach,- irrita-tions of the minims meniloancs of the month, i in:, Ws disease, Kona-

229.11tit)

koff's disease and "alcoholic pellagra." Physicians generally believe theseconditions are caused mainly by nutritional dAicienciesd 31 118

Resistance to Infectionthe lowered resistance of alcoholics to premnonia and other infectious

diseases has long be.n known, and is usually attributed to malnutrition.Recent research at Cornell University has shown that lowered resistancemay also occur in wenoutished heavy drinkers, and appears to resultfront a direct interference with immunity mechanisms. NVith blood.alcohollevels of 0.15 to 0.25 percent, produced by intravenous administration ofalcohol, the inhibition of white-blood cell taohilization was found to beas intense as that found in states of severe shock.21

GoutAn old tradition is the belief t port wine is the cause of gout. A na-

tionwide study conducted by a ,group of investigators at the University ofCalifornia has shown, however, that more than 60 percent of all goutypatients had never drunk wine in any form before the onset of their dis-ease.'"1 In patients whose godty attacks seem to be precipitated by ingestionof alcohol, physicians have often noted that sudi factors as mental stress,infection, cessation of physical exercise, or ingestion of purine.rich foodswere also involved.

The Hangover'11w hangover is a common. unpleasant but rarely dangerous after-effect

of overindulgence occult-Mg in the moderate drinker who occasionallytakes too much, as well as in the excessive di inkcr after a prolonged drink.ing bout. The exact inethanism is unknown. The symptoms are usuallymost SCAT]. c many bouts after the peak of the drinking bout, when littleor no alcohol can be detected in the body.4s Although hangover has beenblamed on mixing drinks, it can be produced by any alcoholic beveragealone, or by pule alcohol. There is inadequate evidence to support beliefsthat it is ct used by vitamin defaciumics, dehydration, fusel oils or anyother ron.alt.cdioli«cauponcrits.

\o sznisfaciolv specific ti taunt:tit for hangover is known, and there is notills ib1(1 1.0 ,111)1JOT 511(11 1)01)111ar remedies as coffee. I :UV C14.

( hill pc plats. steak "Zlikal;P:IS," sitnntiii preparations, ofsuch thug, hathitmatcs, thyrnid, amphetamine or insulin, For genet altteattnent, physicists Itsualk ptescithe aspitin, bed test, and ingestion ofsolid fools as soon as possib;

Effects on Longevity'Him; is little evidence to thmonstutic %%holler or rot chinking has an

appletiable cite( t 4a11 longt5it. Ficquently tided ate the findings ofPcail. who lepoiltal the shoitust life cxpcktainy lot Ilea% It

5111111N.110l bight (ApC(l.1111. 1111 .111,Lii111. S. anti the highest ha mod: talcinkets.1" 11'1

23

VI. CAUSES OF AI,COI-10I,ISNI()%t r the past detailts many dilictent fat tots have been suggested as the

cause of alcoholism. None has set hien accepted as the single causativeagent.

i'llysio!ogical FactorsMuch effoit has been exerted to find chemicals in specific beverages

which might be responsible for alcohol addiction, or physiological, ntitriBonet, metabolic or geneti«iefects which «011111 explain execssie chinking,To date, these attempts have not succeeded. So far, it has been impossibleto produce clear -cut ;ilcohol addiction by ;miry practical means iu experi-mental animals.'A

Although alcoholism occurs frequently in the children of alcoholics, andthus may scent to have scone hereditary basis,10 it also oceans in time chil-dren of devout ztbstaineis.1 3 Anne Roe and othets have ol)setved thatchildren of alcoholics can 1 n. protected if they ate teased away from theirparents.60 mfr' 'Ibis has added to the belief that alcoholism is related moreto enyilonment than to genetic factors.

It has been suggested that alcoholism is caused by vitamin deficienciesor hoimoole imbalances. For example. 11111(11 research hy Dr. RogerNilliains and his associates at the I7nieisity of Texas I I 2 has demn,anstrated

that increased alcohol intake in experimental animals may be induced bysuch deficiencies, but his findings have not been found applicable inhuman beings. Most of the nutritional and liottrumal deficiencies observedin farachainical alr.holics appear to be icsults rather than causes of exces-sive drinking!'l

Allergy has been blamed for sonic cases of alcoholism, but theme is 00p/001- that al(011011(S ate gunutall allergic to alcohol itself oil to othercomponents of alwholii ixsera,ges.

.11though it is factinently said that alcoholits :Ito' unable to metaboli/ealcohol as rapidly as normal boils ichrils. 1C(111 itst filth has indicated thatlitany actrtaliy nictaboli/e it mote mapitlli when the. :ite iiiinkin,g1Vhether Acolieli(s inetaboliie alcohol in a clilletent matinet--pelluipsthtotigh i!itictint (11/)itritii 13114 .55(5 /5 1101 k110%11,

It his 111(11 NII`AgCSI(11 11(1i0(111 111;11 11(111.1(11,111 111:1\ be doe to (cttaintontitontnts ittc,cnt in beer. wine, whiskey, 1 11111 and Inandy.

1115(stigations hate shim!), homy( 1. that alcoholism also o«lirs hm Hsu%of alcohor( Inyciag( s sirs low in thoe toompoimcnts such Jo. 1,1 arm% in`;%i lit 11 .001 1.101.11111. .11111 1015.,1 111 klls,1,1. P,11.1101 .1101 lilt' V1111( 41 S1,11,:"

g!l :17(1)10ills111 vtrttilt1 ht. inipti,sildc stith0nl .I1( oho]. tilittli,11 t,n;no mow he torsi hitul it sole (mist. Ili, mew ige ( he «insidtmol. the,((de (amt. of diyoue. om slit tub( tt lc lintillmm. the ofi Ani ok t0br mt mitosis.

If addiction ss me (.,11,(1 (lithely oi (1(11 litith by tow-cytisint. to

3

alcohol. the highest rates of alcolr-Aism might logically be expected anton,groups with the highest pet capita intake of alcohol. No such generalrelationship can be found. Although a high alcohol intake with a highrate of alcoholism has been reported in }lam-e,1 111 a high intake but a lowiate of all has been repotted in Italy ;$ and Greetie,16 and it rela-tively low intake hot a high alcoholism rate in the United States 70 andSweden.132

Lven though resean h to date has not indicated any chemical, physio-logical or genetic factor as a cause of alcoholism, the possibility that sucha physical factor exists cannot lie toted out. and (untie,- investigations ateessential.

Psychological Factors

It is believed hy some people that alcoholics are psychologically -differ-ent,- that they possess it sootier 01 traits which in common make up the"alcoholic pinsonality." Thee k, however, no agreement on the identityof these waits, nor on whether iii( may be the causer or the Jesuits ofexcessive drinking.

Psychologists and lis)chiatiists hate described alcoholics as neurotic,maladjusted, unable to (elate etlec tii-c1). to others, sexually anti emotional!)huniatme, isolated, dependent. unable in withstand frustration or tension,pooll) integiatcd, and Imo ked by deep feelitti, of sinfalticss 0110 unworthi-ness. Sonic base suggested tha al(oltolism is, a disastrous attempt at theself-& ore of an unseen inaer conlliel. Ind might well he called 'suicide byinches." 141

Fiend ;.tici (»het, imposed that cxcessise chinking ma) represent at1(1111)1s to 11.1311:1,5 11111111,1 11111s 1110110,CM111 11111111(1',. 31101 11111, the "two-fisted, lie -roan" thinker is in teaks thinking lustil) to tour 111, under-'sing lionmscsotal diisCs. Still othets hair ttttihuted alcoholism to anuntons(ious need to dominate, or all ottcolpt t17 cs1;tlic flow guilt feelings.or On inability to gist: or at, ept »inkiness in lose,77, Nfan) icsearchersbase attumulated data to demonsuitte that alcoliolits often come from',token or tinhapp) holm. ;old 11-.1(11I5 lit serious retotionnl dcptivation

their thildfIrmil.`' bit 111;111 5 03 1[1('Se /,1111(4 (1111111t3CS '1111 1,,Teli

cores has e 10111 1)1),(11 11 in 10111 toll W0111(711 11 1111 ale not 11(c/1/011111 6111

511177 1110y 1)(' 1,1111(1 11114 [10171 11/01 111111/10, 111 11 5 ,i1le 11s,101t111C111 11 111(11111

/1111104111,7 11,11 1111[71 31(0117,1, 177 515CIC 1117(111),(2,, 111 1110 111 1 5 15 1 11 htleadittt tc,tydri1)17 trotro.,!

II Ilict .11, 11c,,,,r1:111!5' lit 0 "pre-01i pAson:tid) -- its speithtations ate pooch defined 1111 r7[17 ,01111 1/17 1,01%,, ;1111

77(111 10 01111. 171,1115 117 1111 111C111 0 1 111111,, k11175117(1'2,1' 171 the 1111(' 11,11C11

1J15 11551t07bp,4it,ii 11(1111, 111 47 111111,1i also ;151,1 Its 117/1h1 1 11,01,71i

S(11 11 ill 10(111 1';0

1[0711L11 11717 IL,i 11,11111,11 111 1111 1 117 111 11115 .1 '71111111' (117 111

pli1,7,1,417,71 eil iOi111 011.1 c,t1,1,c AI 7711711,111 s11010, 111 ,1 (fillet I 111

.7/10 .11c //711 511 111/1:2, /71 17 1/1/7[117-, 1( :;.11711 115 1/11/11 sI/(7/11,1s a, 11.oti(it-

1,t15 1111171111111 111'4 .7141 lo 711 111,111% 173,11 111.11, 1 1'.0 1% 111 (lie [7i 11 11 soli11,4,1 , 101 0 1,1, 1111771(111, 1111561,4%, 1P,,11111412.,5,. 111171 It1,7'1. 111111101 .10111110

31;

pology ald epidemiology, ,nese new studies have been aimed at determiningwhy alcoholism is widespread in some national and cultural groups but.rare in others.c2

Those with the highest reported rates of alcoholism are classed as high-incidence groups. "Hwy include particularly the northern French, theAmcricans--especially the ;rill-Americans (but not the Irish in Ireland)-the Swedes, the Swiss, the Poles and the northern Russians.

By contrast, the relatively low-incidence groups include the Italians,some Chinese groups, Orthodox Jews, Greeks, Portuguese, Spaniards andthe southern French.

Differences among some of these cultural groups are reflected in thecomposition of };coups of alcoholics studied in the United States. In onegroup analyred in New Yolk City, where available figures indicate thatroughly 10 percent of the total population is Irish, 15 percent is Italian, and25 percent is Jewish, 40 percent of .he alcoholics were Irish, I percent Italianand none Jcwish.77 id. an extensive Califotnia study. in an area with largeproportions of Irish, Italian and Jewish inhabitants, 21 percent of thealcoholics wete Irish, 2 percent Italian and 0.6 percent jewish.153

It does not scent likely that genetics cart adequately explain these vari-ations. Va lions invcstigatois have repotted that alcoholism is decreasing7nnong hislyAmelicans and Swedish-Americans but rising among second-:1nd third-gcncration ItaliaAniclicans.15, Some workers claim that therate may be rising among Italians in Italy, especially in Rome and othermajor cities, apparently paralleling the use in personal income. slightbut distinct nice has been noted among Jews, particularly as they tend tochange from Orthodox to Reform attitudes.124

Similar studies have shown that the low tates of alcoholism exhibitedby some gimps cannot all be aulibuted to abstinence. Most Moutons andMoslems, for example. do not chink because of religious beliefs, and theiralcoholism rates ale loss. But other wimpsespecially the Italians, Greeks,Chinese and Jews-----contain stay high percentages of drinkeis and manyof then, use alcohol abundantly, For example, the per capita alcohol con-sumption in Italy is rated second only to that in France. but the late ofalcoholism among Itali:ms is relatively

In a study published by the American Medical Association in its manualon alcoholism, Di. Seldot 1). Bacon ot Rutgers Univeisiry compates twoAmclican groups

For Ity Orthodox Jr-ter

"The social functions of diinking are strikingly clear. Ibiuking isis to (haw the lamil togethei, to keinent the bonds of larger won,'inemlniship. to ;utivicte the relationship between man and deity. Thisis unilcastood by the pal ipants, 1 he rules and pulleduies of drinking are about as diose of a uniscisits tootball guile of altturh scuice. Viiikrtiims of the Ildes. or siolmions of 'inoptiet while

drinking. :nu quial and scsciel innali/cd.1 he custom is Icatued born infants: it is instilled :it the time t:Iat

basic mina! mtittides luaincil and is !might 1)y pit,tiguful int mbcisthc group Wait iris. !alibis, elders). 1 he custom is closcls entwined

v.ith family and religious constellation.. No :.41eat emotional halingabout drinking as such is pal thulaily noticeable: there hate neverbeen experience with prohibition; tIclie ale Ito abstinence Inocc-'Items; there is no 1)iottysia( (lilt or waship in drinking. 'Afenthers oftins ,group slicer at other groups that exhibit drunkenness . :kJ!

members of this society chink, they do so hundreds of times everyyear, they use hive. wine and distilled spirits ... ;\1(oholisitt is poe-tically onknown."

For the Jr/Orr-Saxon l'rote,cl(nt grouf)The social functions of drinking ale rather vaguely and somewhat

defultskely (lesclibctl; they carmen) thaYsing People both familymenthe's and also complete %a:angelstogether, often for PH/posesof 'foe,' often to allure relaxation non" (rather than, as in the ptered-iug (loser adlictonce to) inotal nouns. "I he toles and pro)cdtucsale on 01(asion 'other specific, but also show enormous variability sothat a gicen individual may follow one set of roles with his family,another with business or professional associates, and a third on holi-day occasions, and show (Act) dilletent patterns 1(11(11 Iron) thehome town. Sanctions for ciolations are exttcntel) iii gular, lang,i1nrflout a(Eepting lattglucr t a Siolciti physical attack . . . The customis generally leatned between the ;ages of 15 and 20. Sometimes thelc:lining sums not from patents, ministers, plwicions, eldels, and[cache's, but limn other adolcs«aits. hen. is ,Great emotional ler-lingabout the problun on the mass Iccul as we'll as by individuals. .1(ti-Sidi)1g the custom, especially by the young. is often attended V1101 feel-ings Of guilt, hostility. :111E1 es.hibitionisin, ;111(1 may 0« lir IS at sec (tilepracti« insofar as parents In emplotts ()I darts ale «m«.1 !led

hips th,ec-citiat Eels of the malcs ON(.1 15 yeals of age ;111(1 perhapsreset uncivil' of the namtles 1)5(1 Ir yea's 111 age use alcoholic hoc!.ages, thcic !ruing not too 11111(11 use cat wine, ic Luis ly gleatcr use ofbeet by meth and use ol distilled spirits . .11(oholism is not t(tein this gimp. l'calrips 3 to 7 ol 1511y nut rm.s of alcohol ate

1)r, ,111)cit Ullman (1.11 1115 S11,,,,f2,, ',tell that the !Ate of;II( (,114,011 IS .,41111111, in which the (kinking cttstorus, salticsand saw lions :lie well-estalAi,11E(1, kinnsit to and igiccd upon by all, andconsistent with the lest «) the culture. Hy (outi,ist, the late tends to beLigh in ,12,1(nips 1..0.11 mai ked antbivalcrue 1,10 u1 alcohol rvith no ;tweed-11pon ground Hiles. NVIten such ( 1.itlt icsialiant picssutes,guilt feelings :111(1 tot(cokiinties, tLe .11«'111,1;51"1 rate may lre stay higli,1 his has been ;tonal among the ielaticely 'Afotilions (slur (li ink, :11110114iiniciciatc inkcas who 'eel toned to Inevindulgenic Cr) pto-c theirliness.- and cspc(i.illy atri.111.,4 addict' 411 patents Icith «mllarimti attitudes- 511(11 IS a 11111)1 ,11,1 sees 1111111,111:4 .1 11111111' ;11111 111111111 W114) (Ills

chinking is .1 sin.111 loll siguilicamc ni sin!' ambicari feelings as a (alas(' 11f ali,holisin

is era Antmin(d. It ni.1s bear list 11)potlic.i/,d. litocu.1, tli,(1platy mit ion'.

In general, research has sham that for groups that use alco.401 to asignificant aggro-, the lowest incidence of alcoholism is associated withcertain ha bits and a ti it tides:

I. The children ire exposed to alcohol early in life, within a strongfain ily or religions group. Whatever the beverage, it i.., served invery diluted [Orin and in small quantities, with consequent lowblood-alcohol levels.

2. Vie beverages commonly although not invariably used by thegroups are those containing rela tivgly large amounts of noralcoholic componenis, which also give low blood-alcohol levels.

3. The beverage is considered mainly as a food and usually consumedwith meals, again with consequent low 'olood-alcohol levels.

f. Parents present a constant example of moderate drinking.5. N moral importance is attached to drinking. It is considered

neither a viltue nor I sin.6. Drinking is not viewed as a proof of adulthood or virility.7. Abstinence is socially acceptable. It is no more rude or ungracious

to decline a di ink than to decline a piece of bread.8. Excessive drinking or intoxication is not socially acceptable. It is

not considered stylish, comical or tolerable.9. Emily, and perhaps most important, theie is wide and usually

complete iigrecnicnt among members of the von') on what mightbe called the wound rules of dtinking.

39

VII. I)IAGNOSIS OF ALCOHOLISMThe moderate drinker is easily identified. He thinks only at reasonable

intervals, maintaining low blood-alcohol levels. His drinking clots notinterfere with his health, his family, his work, or his community life. Hecan readily control his thinking patterns, modifying than to what is appro-priate for the time and place. Unlike most problem drinkers, who seem-ingly think to relieve tension, the moderate drinker his a wide variety ofnutritional, ine.clical, social or religious reasons for his drinking.

The last stages of ocivon«11. full-blown alcoholism arc also easily recog-niied, The victim is usuolly complete!, unable to control his drinking:he may no longer have an established bitnily life or be able to hold a job.Thew may also be malnutrition, cirrhosis of the liver or other tissue

1)etecting and diagnosing the hoick:aline states of harmful thinking,howeser, and doing this at an earh atage so that appropriate treatmentmay be stai ten. 5 a dillcient and fa' more difficult task.

Unfortunately, then, IN 110 '1V,INSCI11111111 test- or other relatively simplediagnostic plot «WI C {01 ;II( oholi 1)etennining the !newt' point atwhich manageable thinking stops and dangerous or addictive chinkingbegins is os L-,cpossible as pinpointing the exact nimnent when safe drivingstops and dangerous diking begins.

The \Val-1611g SignsInch% idual saliation makes it impossible to present a complete list of

signs and symptoms uniformly triiiing the eolly stages of problemdrinking. Familim signs ale the need to think before facing certain situa-tions, frequent drinking spites, a steady increase in intake, solitary think-ing, «lily motning thinking, Monday 'mulling absenteeism, hequent clis-pmes about thinking. ;With the occ intent e of what are [coned black -outs.

Fm a drinker, a Idatkaint is not -passing out- but a period of time inwhich. while remaining odici wise hilly «mscions, he tutder,gtucs a 1( lss of

rlrcrnotl. lie walks, talks any acts. huh tncs not ICinellibei. Sulk bLle k-otitSHia) repnescnt 01Ie 01 tic Cal 1) sigiv, of the mote suitor; form of

llut altohnlism may be plusent without black-outs, and without any ofthe other populaily ott ivied symptoms of addictive thinking. Many olio-'Hillis do not go on thinking specs, or drink :done, or chink in the "limn-ing, in tills work .n Mund.is,

fn gt tit 1.11, all 111110 1(11I,11 111,11 1)101i.i Id? be considered an alcoholic iflee (tint tines In stink c s, n t1147111 his thinking ((insistently causes physical

gaol i4 disticss oh balletic(' In- ennsisttn11y causcs

notildc 1rillt his Will', Isis t 1111111kt , 1/) theInif), /11,1i inn gcncialls :uteried chaiactitistics of alcoholics can

40

usually be obtained front physicians, medical societies, clergymen, socialworkers, Alcoholics Anonymous, State or local health agencies, and nationalor local alcoholism organi/ations, For an individurl case, however, properdiagnosis may require the services of an expert Often it is necessary toawait the passage of time to determine whether the individual his failedto heed the signs cdrvions to °diets that his drinking is causing significantlama re.

The Diagnostic TrapsOne of the major obstacles to correct diagnosis is the view of many indi-

viduals, both physicians and lamcn, that anyone who chinks less thanthey do is not an alcoholic, or that the only real alcoholic is the Skid Rowstereotype. A recent Massachusetts General Hospital study 12 found thata diagnosis of alcoholism was more likely to be made if a patient werepoorly clothed, unshaven, separated from his lapin), unemployed or introuble with the police. But the correct diagnosis was like!) to be missedif the patient were well-groomed, living with his spouse, emplocd, withno police record, and possessed of health insurance.

In some respects, it appears, the redefinition of alcoholism as a formof illness, a public health and medical problem, has gained more rapidand complete acceptance among the general public and alcoholics themselves than among some menthe's of the medical profession.

In part, the reluctance of some physicians to diagnose alcoholism matbe due to a sense of futility and a feeling that they do not have adequateresources or experience to provide needed treatment,

41

30

VII I. -IREXIsN.IEN'I' OF A I,C01 I01,11SNIThe alcoholic who needs or seeks help faces at the outset a number of

vital questions.Should lie begin his search for help with a relative or a welhneaning

famils foetid? \Vitli his family physician. ;I psychiatrist or a worker fromAlcoholics Alionintis? NVith a clergyman or a social worker? (:an he (tire

Should he be treated at home, in a sanitarium 0:. in a Ito:pita!?Should he try to taper oil gradually or stop all drinking immediately?

Should lie look to thugs or psychotherapy? Will his tieannent tequireclay, a month, a year or longer: 1 1'hat are his chances of recovery?

Many of the answers will he dictated by his personal prejudices, hisfears, his finances and the pressures of his family. Other answers will beinfluenced subtly but power fulls by community attitudes toward alcoholand the alcoholic. Some mas be influenced 1.)) knowledge of the new ad-vances in alcoholism tlictaps- knowledge on his own part, and knoisiedgeon the part of his therapist.

In any effective .State 01 local alcoholism ticatment program, it is tleallycssehdal that ;lit oluifics ;iinf their lelatises- -as well as ptissicians. Clergy-men, probation °fracas, pelsonnel workers, social wolkeis and 1 ;crimp, socialagenciesbe provided with sound, up-to-date information on the tspes oftreatment available in then own tommunities. the pietist, locations wheresuch therapy can be obtained. the probable costs, rind the possible lesult.

Preliminary TreatmentSome alcoliolits will begin treatment during a stage of Rittpot sobii,

cty, whets dining the throes of a st eie hangoci or dining at ore intoxita-lion. For many it will be (locale, the fining -out or witlitliawal stage, markedI)). such tontlitions as delirium Hemel's. In some cases of ;lime intoxit allowand in most with sctele s)inpumis, tompctent meditalWent diluted by phr,ici;d1 is essential. \\*idiom sorb tare. the patientmay die.57 71

111 the past, tit:mint nt of wirhdhatyal S)1111)(0111S was based hugely On Sitt11:11(01101 st11)S111liles as (11101,11 1111;11e or 1).31;11(:11)de. 111 the kst 15 scars,these thugs hate been leplaced in put with new synthetic 11,111(ittilift.is

such as h15(1 pine, 111olittoin;1/int.. tittplo)battntc. ptoitLiiinc 11)thochlotiticand thlot(ftticpo\ lic impact of these natt(111iliiing tilltg; 011 theIICAIIIIc1)1 of 111' acre altoholit stage has been clescrihul by some tfillicialicas it solid ionai 11'ith ,,pplopt idly 1151 II ;11111 shut thchi.

tspi ci.ills till (ot.ttol of Enid .ttid (1(1 tioltu 1)11,tit«.. loos'p.itit oh 1 to% t 1)11)1411. Horn dcliriutu. 11.1111,1611.11jull, and irtincos. andAre tcadt 10 .0:111 4)0111 !onus of tccalmcnl.

ilospital Admission

An t-ittely ill ;11colicif, tit the ,,holic %dm is acittel,, intoxicated--may he .given satisfattoi. talc It home, 01 in a special detoxification orciringout center, but a general hospital 11;ml is considered the best settingfor ptclitnitial tie;,tinent, .k foe Anwitan 1011 Canadian general hospitalslmve long ofleied iatell core, but until the late 195(1'5 neatls all hospitals1.,cre reluctant. to :.crept alcoholits as patients.

Tilt traditional position 01 most hospital officials has been attributed tohostile feelings evoked b the so-called tpital :;eoholic patient, who atadmission was often (arty, dishes/led, distutbing and dcmanding. If thepatient were laoistcloct. it teas difficult to think of him as sick. Often hewas 11 kW ed IS (VC:11)111\ 1114_1(1 :111(1 '11111110)11, 11)111(111S1e to other patients, upset-

ting to hospital ioutine. and likels to assault attendants and nurses.,k wealtla). o prominent patient might he admitted- -often under a

(4111101111.11g(1)1 (1141.)41111si\---1)11( 0111 \ if 1111 paid for a pi ivate loom and 2,1-hour-da) pli1 ate 11tH (;tie host patients. unable to afford such (ate, w,Te

scut to the "chunk tank- of the lotal jail, the ps)chiatrie Ivand of a Statehospital, or the einetgeins wind of a lo1:11 hospital. In most eineigencyscalds, atte:celants (011«.1ned thenisek es pitinatily send] sobeting the pa-tient, nualing olysitcus %%aye-lids in contusions, and discharging him asquickl as possible /Itecl 1 less' das 10 weeks later, the same patientwould 1:appeat Ill the s onc: tpe of templaai

l'ild,;11)1 the inn,r 1111cm (Iumnn5t1;11ion that this technique leas out-moded and needles, ill I.I. "17 at Salt Francisco's Yount /ion llospital,9;lite/ officials clecich cept alcoholics simpls :is sick people needing

hospital "it'. These I' lilts 't,"(1c Plat"' in 1112,idu open "itls andtreated b pinsicians, anises ;aid odic] pelsontiel who had been eatuluIlitalinal in the use of nose 111 11 11111 Ot It'll It'd 141 11(1.11 (11(1111 as 1).111(1111S Ic110

Were ill and 1101 WA ss )1 ,

It quickly became (aid( In that tithe] patients wek not clistutbeil, hospi-tal toutines wale not mpset. and most of the alcoholics %vete willing to111111 tt;t1se followito thetap,

I IiC ;-1(11(1-11 (il the (11 lig', has made sedation safe", simple]and mole (tilt (live, and has c!,,teoils fat ilitaltal the musing and medical (aleof the detoxification and icitlultawal pia tepotted Dr. jack I). Gordon.the dituctot III the stial. Ill addition. 41.;1 int leaStal 1111(1(1 \ 1111141illg 01 the

( /111)101,..,,1(:11 a5p1(15 III 11111( 55 11i \ 1:14)1111:IA11 1:s III 111.1! 1114 411101:( in ;1

1111111 1,1,111(1:lig ;11111

nation. Thu ;11(4)114)1i( ,1,1111 1 oth In chug. ,11111 the auno5phcrr, ;11111

li;o, become manageable1 he expetiment cicintiosttatcd, fits(, that modem hospitals can meet lei!

cominutiii) responsibilities in .rltolicilism dictap, 11111 111, 411111. 111111 1105111-

1,111/4 41 Almliolit 1.,dicrus 'Lir:ill: 1 .1 111.,1 111,1,1 do

iith tut 11

,%1Ilioli,_;11 rill sIl t 55 at AIl, lit /1,41 11,0,, Intn dtipli(.ocd :11 11111(1 11nspi

1 41 ,411,41 14.11111, rd 1111 \ 1,1111,11 .11111 lilt' 1 it .111

I 11,1,?r.11 : in1.11 tht,m dunt till 1,11111111.,.

this ,111 still III 11111142, III

12

.1i(101,ill IS 11111111,111 11 1114.1)1,,

4 3

The strategic importance of the therapists' :,;litude dining rhe.e cadsphases of it Cat vaent has tecently beer, emphasited by the IeS111tS of a re-search project undeinkcn by or. Moms (:hfw. ;no his associates atAltu tichusetts (;cncvai ilositital.'.!.7 Stnii)ing alitiholii patients admittedto the emergency ward ser.vites of the hospital, they found that nicecing thepatients from the outset with i.'IdelStainling, Spnpath), and attention toexpressed needs could assure higher rates of follow-through on treatmentrewinmenda dons.

Drug TherapyOnce over the acute stages of intoxication Or withdrawal. the alcoholic

starting long -tange treatment Ina) requite a kind of pltaintawlogital hiielgeOver the difficult eatly (la), or weeks. For this, pli)si(ians ma) prescribe avariety o neon/lents,

Tranquiliiers ale often used to produce t-elaxation and to 'educe thetensions which man) altoholi(s !who(' to have 114,,gcred Ihcir thinkingT7011(5,14 56 '111e) are highly effetti)e, but sonic ;1101/11()HCS \ becomeaddicted to the Vl y tlit11(11111i/CIS tcititit helped uncut htcak away 110111 Ihcirdependelley of ;1101/1101.

Other ph)Si(iallti use what is stnnetinter, tailed (onditioncibicsponse oraversion thelap), ;trIturtlisteting of al«tholic liecetage and at du, tame time

powerful natiseapioduting agent like (aiming or apoinolphine. Repcatidtreattnclits with such ;lie intended to tlec lop a conditionedtellex loathing fur alcohol in ;Illy 10110. Ilcc,ttnc of Ihr risk of sconecal reactions. this method of Iteatnient tecptitc,i (lose 71

wide], thcd 5.4,111,11 (1,1c,,,,n1 agents smelt as di,111brow (.Antalase) and caibitudde einposili. A patientregulail) taking our of these (multi ant's finds that ingestion of altoliol in

any foto' quickly piodu(rs pounding he:lib:tin thishing. and usnall) sinlent nausea, vomiting. ;tint othcr unpleasant s)migonis.l;

Plobabl) the glearest these and sintilaa thugs is ilia; tiles plot isleteal if Dill) icitipolin) relief lot titan) patients. Fir ittost ,anima., 11011 eNer.they tan produce lasting hinefir oils as part III plogiam pschcithciapwhich attempts to gut al Inc tintnion;i1 facinis the drinking ofthe alcoholic.

Psycllotilerai)y

Iii the past, alcoholics hate ficeit ailloottished. sioldetl. di trounced, j.rileif.beaten ducked, lashed ;Ind thicatened with eternal damnation. I Iliac is

no cidetne that an) of these incastilis has frail signiftiant therapeuticvalue Inv mole than all iticisionallle1111/11',11;lte ton he mInt.lcti piilII i1 b) ,t

nitric known ticiall) as ps)(hothtap).psyi hotla tap) is a label (muting sal iorts kinds of selbixamina-

tion, rininscling and guidattie, in plot It a Pained pith ssiitual tirik% 1,1111{r.Ihcr than WI) .1 llt- II MC of in nonl,s to hoIp 11611 110 le2,e

Itclin s, altirndts and 1( h.! \ HI in croft to like more1121 lc I 1C N,/li11Ill11,. the 115111llthl I litil .1/11/1.11 in Ow

to,c ril ii511.1115 In Hin; .1111101 ri

44

acceptance of the alcoholicby himself and by the therapist--as a personwho is sick but not evil, immoral or weak, and an equally complete accept-ance by the patient of the idea that he needs help. On:e sonic progress hasbeen made, an effort is made to achieve understaneing of the patient'sunderlying (elisions as well as his more obvious prodlenis, to alleviate orsolve those problems that can be readily handled, aro to find a meansother than drinking--which will enable the mien; to live with thoseproblems that cannot be solved.

Most successful therapistshowever they may differ on details of treat-ment---indicate that pleadings. exhortations, telling the patient how to livehis life, or (»Ting him to use more willpower, ate usually useless and maybe destructive.122

\fatly therapists stress the frequent need for including members of thepatient's family in the therapy program. Retiearch by sonic investigators hasdisclosed that the family may include another member who is even moreemotionally disturbed than (he alcoholic. and who ,nay be partly responsi-ble for the alcoholic's drinking.';

Usually patients find that the termination of their excessive drinkingmeans they must face a« twin/met! internal rind cx:ernal problems. Treat-ment for alcoholics, many therapists hold, cannot be conducted on amiss, imelmittent basis, or testti<tcd mainlv to the management of oc-casional drinking episodes. Many believe the best schedule calls for veryfrequent sessions dining the first weeks or months, and then sessions atlonger intervals as the patient pioArcsses. The patient and his familyusually stay expect the 11c;11111(1.1 10 101111011C for at least a year, with thepossibility that he nia occasional temporary psychotherapeuticsupport for many yams mole.

On the other hand, doctms at the Cleveland Center on .Mcoholistn"haste claimed Ater five years cil expelicine with nemly 2,0011 patients thata substantial pnipmlion can be given significant help in bon( one to fivethm.puntic sessions. Clearly not advocated for all alcoholics, this short-Iconpsthotheiapy was found to be most effective with patients liming whatwere termed reasonabb MLitt emotional and environmental I CSOUrCeS

with ,i2,000 family tics and a detemninat'an to get well-----and whocould, with help, fade reality of thc:i situation quickly.

he 'IlierapistIn the cally stages wan, indi,,idird, ate able co

recline tfich intake oil clan stop chinking on 11101' OIll 1.01 IRA iOdS of

If they icsenic chinking and rim) bcconus cidcm, sclfleatment isCoinpout piofcssional help is essential, and usually the cailici

it is obtained, the lietit the Imigreon results. man (Hp:, .11 hull, ;IJ;11;1/1 Wk.

"Lb,.

I ;1(1(ti( r in4 «oiNid(R(1 at sin .aid itsthc rt low, .1 'tali/41,1)11)11 (1(141. l'ntil Ill( 11111 111C (11

1 liltjt)tr, 1,11 ki s III ti vtas (sstinialls 1,, ad ton i to in

45

duce the sinner to see the error of his trays and, with Divine aid, to mendthem.

This situation has now changed considerably. .After deep re-appraisal,many eletgymen of various faiths have taken a different approach, utilizingmodern psychological and psychiatric knowledge, and are following thepattern of pastoral counseling provided genet ally for people in trouble,

Alcoholics AnonymousAA has been described as a loosely knit. voluntary fellowship of alcoholic

gathered together for the sole pinpose of helping themselves and each otherto get sober and stay sober. It has also been pictmed as seising its membersfirst as a way back to lift and then as a design for living. Widely publicizedsince the early WIlt's. it has more than 7,000 local chapters, with out iiialmost evety slreable town.

Important to the .A .A approach is an admission by the alcoholic of hislack of power °vet ;tholtol, lie must hale hit what is telined "rock bottom,-finding himself in :t desperate totally intolerabm situation. For somethis realization may come schen they have lost (leis Ong and evelybody.For others, it may occur when they ate fust attested by the police or warnedby their employer. At this point, the individual must decide to turn overhis life and Otis will to a Power greater than his own, Nluch of the programhas a spiritual but non.sectarian basis.1

During the early years of AA, some membets lightly insisted that 'onlyan alcoholic can understand an alcoholic." and :hew w:1, minimal coopera-tion between . \.\ wmkets on the one hand and physicians. clergymen andsocial workers on the other. With the accumulation of more experience andknowledge, however. most AA inembels no longer hold these concepts, andcooperation with duaapists in other piofessions has been increasing.

Many. physicians emphasize :hat. t Actable and widely accessible as it is.

A..1. should not be «insideted as a «nupkte bum of treatment for all alco.holies, but should be viewed for most as an adjunct to and not a substitutefor various fowls of professional therap).rtt

Physic-1w(

If a/cohodsm i, by definition a d wase tteatment should logically beginunder the direction ol a physiciar. Rut at least in the past, many physidans have been tedium' to accept :Lhoholic patients. :\ 10 Ili study in NewYolk. for example. showed that 60 pcicent of 1.6011 doctots repotting didnot treat alcohol addiction, 111(1 alcoholics made up only tine pcucut ofthe ['lattices of the other 10 petit:110 211

"The situation has intpuoved 111:114dly `NIIII(C then,'' as Di. Nfarvinchairman of the Aunrican Medical Association's folluct Committee

on .\lcoholistn, "btu it is not imposing (wit 1...1) enough.- . \i least partlytespot (able, he claims. is the teaching plogiant of most inedic,11 schools."With only. a few exceptions, most schools devote less than two limns outof a fooezu unlit ulnin to the studs of mutual and abinumal chinkingand the treatment of all 11111112 time learn,

ing about tate discas... (slii(11 duy may lama enwonicr in their plactice.he says.

35

In general, the techniques of psschotherapy used in the Deatment of...dcoliolism are no 'note complex than those used ill other conditions, and(an be learned and utilized efleoit el) b) family phssicians, internists andother medical specialists,

Other Specialists

\ \'ith special raining, clinical pstchologisis and psychiatric social workersin many communities hate mulct taken lesponsiftilits for the dons; -terns (ateof alcoholics and filch families, usually working as menthe's of a therapeu-tic team. Vocational ihabilitation workers, public svelfaie caseworkers,visiting muses, and plobalion and pantie officers hate also been trained tohelp alcoholics. as hate mans pelsonnel wolkeis in inclustis, who hateoften been the first to detect the least thinking of etnpfo)ces and startthem on the oven to neannent.`,

.Sperial Frinri Alitlictaltse the chinking of all alcoholic may set ionsIs r,ther tucinhers

of his familt- ;111((ted bt them increasing attention has keen ditette:a totvard treatoutit of the famils as a whole. 'This has sometimesmeant the inclusion of the patient's immediate lamily in the therapy group.One organization. .11-.frort, Lis Inen established to help the wives andhusbands of alcoholics. using ft( Innifitts titular to those of .1.1. Anothet,.11-.11(cm ls (looted to aiding, th«hilihcm of ,11«,holics to understand theirpawns' prnblons and to ch %clop 'note ellectit e sear, to handle whateversocial ;11111 emotional dillicullies tilts themseltus may be expetien(ing.

Individual vs. Group hetaps.some experienced thclapists claim that individual ticatment on a one -10-

one basis is the most stu«sslul. Othe's preler group thempt, especiallyMut' a gimp 14 patients is neated sinuiltanconsIs bt a team ill tfurapists.

It outstanding example of the 'act(' ..-Ippio:«11 is the State of CleolgialsGcolgiati Clinic in ,\thinta, (11n\iclinn hurl the beginning,- sass Dr.(Inclle Fox, (Hitch)! of the clinic, "Ivas that these patients Isce sick in

mind, hods and soul, 11 [het out to a single theitipist, the) would getone attitude hone the pssehi.lttist, one hone the internist and one hum theleigtinan. IVe felt we needed «msoliciatell :rnitude from all Once."kith a stall of spc.1 Lilts trained noises, social

workels, pss(hologists. slic;ctional ichabilitation (ounselms, o(clip3-10,1,11therapists and cicr...,tiuen of Imins faiths. the clinic opened ill 1953. It nowmats %/Ilion 'is patients limn all mei the Stale., tither as 11111,1liClitc,

11:1 ho,pii,111 111,..01! 110,111tar 11;111C11h, or snore conthilia

(ion of these. If possibk. patient begins Clump lit ing in the c(ntc1 lot how suer to 1111 (Liss %shift. intcnsitc (11,1g1101c and

pin,css. 1 111 pl(10.41.111111.1, 1)1.111 (1l,(111)(1,1 11

AIR I phNlibil I .1 I r )11, 111C tittilutt.toes psstiti.fif it-, swill01ttifile.2, in ;In ;111(.1111ff to (41(111111R' his lit.(10.11

ti; 1. Medical ril.magemeni and to pi(s(tiption is begun 'rune-dialers and contintud thiougliout the eontaet. .1 ',elks of orientationploc(clincs follolcs.. the paticiii secs . pplopliate filins..itt(nds personal

:16 4?

interviews and counseling sessions, and pat titipates in Group meetings.Each week, there are 611 group meetings, togethel with 16 staff groupmeetings. A (,rtwork of occupational, l'ec icational at (I vocational ac-tivities designed to aid selbesquession is svosen into the program. Thepatients themselves form a thelapcutie (multiunit). earlier memberssponsoring the newer and mine frightened. This "acceptance attitudetherapy" is an important factor in orienting and sttengthening the newpatient. After leaving the clinic, all patients cire urged to attend groupmeetings ligulaily for at least two yCZITS in the outpatient clinic, or ata local chapter of Alcoholics Anonymous or a (immunity-based clinic,and to continue indefinitely if possible.

In 1961, the Atlanta clinic was capable of mating- 237 inpatients a year,at an asciage cost of about 51.1.53 a day, each. 'Together with zi smallerclinic at Savannah, it could provide day hospital or outpatient care forabout 1,500 patients a year.

Chances of Recovery

In es aluating the future outlook of alcoholics. man) therapy is disidepatients into Once broad groups.

1. The psythoty alcoholics. These ate patients, usually in State mentalhospitals. with a Setile (100111C I/StilOSIS..1 hey may account for use to tenpercent of all alcoholics.

2. The Skid Ito:c ah-oholirs. These ate the impoverished "homeless men"who usually no longer have - -or never did hart' family ties, jobs, or anaccepted place in the communit). '1 hey ma) account for three to eightpercent,

3. The "azTragr" afrohohr c..1 hese ale men and women who are usuallystill matticil and tiring with their families. still holding a job--often aninipottant one -and still ate ;q(ctted and lemon:1bl) respected members ofthen (immunity. They account but mote than 70 pelican of the alcoholics.

From she scanty infotnriticai ici,cilable. it would appear that the ping-nosis for ehionic psyiliotii and Skid Row alcoholics is poor, and that lessthan 01 to 12 pet«nt can obtain S1111,t;Inti;11 ;kid hum oidinaly thetapy. Forthe average alcoholic, the 1)11111)14i is fat mole optimistic. llete, duce (Wha-m' )ardsticks Of (0111101 lane been tuilitrd.

1. (:oulpiete (tire. his sit 61 ill 1111111011, 1111S would mean that the alcolinliiwould liceome able to drink normally using alcohol moderatelyand under complete (onto)]. Most specialists hold that no alcoholic. canever learn to dciiik mod( tatcly and iegaid statements to the contialvvi in

is unwise or dangerous.2. Iir(ari(rif 00,f1rie 'ire. toll 1111)51 the goal of :teattlictit is

tompltte abstinence front any torn[ 111(1 to ...m) condition,for the )(St of the 111's hilt. A(101(1111g to available inhumation, only aswill pciwitagepciliaps Ik55 than 20 pelican cif all ticatecl patients--113 1 1. hall ;11,111' 10 111,0111,1111 Asollite aliktioente for mote than three tolist scats. In ((main high') seicctise industrial and business groups, therate of abstinence may 0 111:0) os VICCIlt.1"

"17

3.1?clinittlitatiott. Recently, some leading therapists have hem using a dif-ferent basis of measurement in 11111(11 success IS cunsidcteul ;.0.1iicxed whenthe patient maintains or re-cstahlislies a good family life, a good workrecord ;Ind a respectable position in the community, and is able to controlhis di inking most of tit(' time.

Depending on the motivation and intelligence of the patient. and hisdetermination to gc"t \yell; the conipctcrice of the therapist; the asailabilityof whatever hospital of clinic Ittilitica, tranquilireis and tither drugs whichmay be needed; and the strong summit Of family, cmplo,sur and (oniuitits

-a successful outcome can be expected in at least 60 percent, and .-,011112therapists :lase repoi led success in 70 or SO pelt CM.

it is doubtful that ;my specific percentage figure has much nteaning ins:..s I)r. Schierl 11. Dawn, director of the (:enter of .1.1cohol Studies

at Ringer' \\11:11 has gic,it (ICJ 01 is rite fact that tens ofthousands of such casts hate shown sulking improvement °ler many years.

There is no esidence that any paiticular type of diciapisti)lisician,cleisman, .\ . \ winker. pschologist or social trucker will tepid( betterresults than another. 1 he chances for a successful outcome appalentl de-pend 11101e on die wolisation of the patient and the competence of thetherapist than on the tsp.' of psychotherapy canploscd. "i he earlier thatit eminent is begun, the liettca rue the prospects for success, although somepatients base befit tteated successiulls alter 111:111y teals of cx(essise thinking.

The Role 01 IndustryA major factor in successful cfcsclopinvnt 1o. Lierapemic resoun es is strop:

support from the employer. first in helping, to detect almholisin lit its carpstages and then in cooperating in tic-mm(10.

Mote than 200 .\inciirati hints maintain their own company programs,usnalls as pail of the «mipaii's indusiiial health 01 industrial relationsstashes. .%11 leis upon tusinikes lit the miniiiiiney for a major par t of theiicatinint aspects 01 the programs.

Alcoholic employees whose citinking piohlenis base heen idintilied ate.gcnetally. uttered treatment at alt Cal 111'1 s1ay1 01 the (.11,,C.ISC 111;111 ale 11117111.ratite(' (II 1 his 10.11 111(.01 01.11 ( ti,.(111 es tell ...rl.(10111 11(01(1' areenhanced: physical health has deteriorated less; financial resoniccs have notbeen so tomplctely dephicd; stone supports exist in the fautill0i(1 tice (otnillmlit; ;Ind s114,11g Inot0ation for f Coo t leas be 1)1°ifica bytincalilluf jab 1tss..'il °I 11" w Lit 1°1' 1)/f'Llin;114! "ffluil'ufc :0 111c 5()-7111.11.1(1111 le(Ol(.11 !die gelleldil iipoiRd for Costs In ill(111Slit fill (onto)] picigt.inis atc .4( 1c1 «aticicled to be negligible in telationto tilt

I Its Role of flcaltli InsuranceParalleling tin on teasing inn ,csi of inductis its alcoholism has been a

change in the attitude of 111,111.111(e (0111p1111(s, \\ 11,Iv most ,,ompiii(s 010c11.1 td to ill( 111(1c the 11(.0111(111 of .01(41111011,M in lie,11111 111.011,1111X polities,

now {,t(A1imv V.11(1 id 0,0 (.1.1g/.,fic 1 (pi (1,1, 1.4.4c tutctotll s,oics in dilicic oicas and for differ,

4:1

ens insured groups, some providing coverage only for the acute phase antiothers coveting only longterm treatment. Treatment is usually covered byState disability. insurance pi( 's and by Many commercial insurancecompanies, with a wide sari ;. the protection provided by unionplans, Blue Shield and Blue Cross.

The Role of Local AgenciesNumerous agencies on the city or county levelprivate, governmental

and religioushave contributed to the treatment of alcoholics and the careof their families. Among the oldest of these are the Salvation Al my, theVolunteers of America, aml sorious chinchsponsmed missions, which haveoften provided help and leadership in areas where no other assistance hasbeen available. Although their programs !Airmaily provide spiritual sup-port, some are now itin sting the services of psychologists, psychiatrists,and internists.

Special hospitals for alcoholics, some sponsored by State or oilier govern-mental agencies, but most pliva-ely opciated, accommodate relatively fewpatients, but many have seised as important research a.td training (enters.

lialfway houses hose become wellknown during the past ten years, serv-ing as intermediate stations for patients whose rehabilitation appaientlyrequires gradual rather than abrupt return to the community.

The Role of State and Federal AgenciesTraditionally, .host State ;111(1 Federal expenditure's for alcoholism---along

ssith similar expenditures by sonic cities and countieshave been appliedfor welfare. To aid the wises. husbands and children of alcoholics, Stateand Federal agencies. working together, pioside some individual aid tochildren of alcoholic poictus horrenvo..2t sersice and day care (or children.guidance to adolescents, le-cducatior. for rehabilitation, training of special-i/cd personnel and the olgani:arn of demonstration projects in publicwelfale.

In the actual treatment of the ohoholic patients themse/ves, governmentofficials are faced with the Imcessity of solving two 1ClalCd plObiCITIS -411%1.the provision of suitable hospital Inla(ilirirs 'whew needed for the shoittelmtreatment of the :Rine stages of hitidialion: -nil second. the pi mision offacilities for htngkaill inpatient al.(1 outpatient (are.

Most workers expect the eventual solution or the lust pioblern will beroutine a« eptam al(oholas by all general hospitals, and the trainingof ncessok persorm "[his, however, would be of limited solo(' unless itwere linked with a full-sc;de, long-min treatment program lot the underlying alcoholism. For longRim treatment, some experts has e pioposed Statenetworks of outpatient clinics- such as om «nnpletel staffed«iter for C1(1) '20000 inhabi!ants, With tnohilc trains of W011:(1% 1)10\ id .

ing paitime .ersices in adjoining «nnmunities. limiest has also becitshown in night hospitals where cmphked ahoholi( s can get rehabilimli%ecare (luting the esenings and day hospitals for nu (hers who cm be treatedwhile their husbands rue ;it work and dui) chil(hea ire school.

Although nhury State-sopiHiliCd Clinics MC ;di cd(1) ire (pia II011, they

50 311

probably represent only a stopgap solution. Many thoughtful peoplephysicians and non-physicians alikeare convinced that the eventual, prac-tical answer to the problem of alcoholism therapy lies not in suppottinghundreds or thousamls of special clinics, but in training and motivatingdoctors and other theiapists to accept the responsibility for treating alcoholistic as routinely and unemotionally as they would any other disease.

51

10

IX. PREVENTION 01: AI,COI-101,ISNIWhile early cascfmcling and treatment of alcoholic's is essential, this

approach will obviorrily not solve alcoholism as a community health prob-lem. For 1110s( diseases, as in the case of smallpox, typhoid lever, pellagra.scurvy and poliomyelitis, substantial control depends on effective prevention.

In the past. the prevention of alcoholism was based primarily on effortsto prevent or at least nrinimiie drinking. Since alcoholism itself was deemedlargely a problem of moral sveaktress or immoral willfulness, the early pro-phylactic actions were chiefly punilisc, threatening, or exhortatise, andrepresented mostly by legal or religious measures.

Legal Approaches: Nationall lie most complete prevention or excessive drinking would be provided

by the most complete prevention of all drinking, such as by the enactmentand full enforcement of laws against the production, distribution, sale orconsumption of alcohol in any form. This has been attempted many timesin various parts of the world most recently. in Finland and the U.S.- -andthe penalties for violation litre ranged from fine and imprisonment to ban-ishment or death. Except perhaps for some Moslem areas, these attemptedlegislative controls have not proved adequate, and in spite of many sincereand determined efforts. no country in Europe or the Americas has yetsucceeded in elinrit ing the use of alcohol by legislative means.

Some exi cuts belies e the rate of excessive drinking and of alcoholism inSweden mf,y have degreased slightly during the 19fi0fs and suggest ilia! thismay be clue in part to taxation policies which make beer and wine mark-edly less expensive than distilled spirits on the basis of equivalent alcoholcontent.

Legal :Approaches: RegionalBefore the Prohibition period in the l'irited States and marry times after

it, legal control of chinking was attempted by Nations States, «sondes andcities. In some instances, these local laws were aimed at the establishmentof "dry States- or -dry counties." In others, the laws dictated the numberof liquor stoics whiell would be permitted, the hours and conditions oftheir operations, the prices they could charge, and the age of their custom-ers. Some States NCI rip ;1 monopoly systcm under which the State itselflipmited liquor stoics, while others permitted such stoics to be operatedunder State license. 'I he clic( IS :111(1 1(1.1111(' .11allutgcs of these laws haveli-en the subject of brisk controscrsy.

A curacy comfmt(d in IfIri3 by a Nfooland Act Commission for the Stateof New York found no «incistcnt relationship lictween excessive drinking-as measured by drunkdi is ing attests,sts, public inuesit ation IiIIICs(S, ZId11134SIOIIS

to mental hospitals, or reported aloilsolisin rates --and sales of alcoholic

524

beverages through State monopoly or private liquor stores. Similarly, noapparent relationship was found between excessive chinking and the num-ber of liquor stores in a given area. The inve,tigi-uors concluded that, inGeneral, there was no eeidcuce that the various legal control systems em-ployed in the 1..'nited States bore an) relationship to the extent or natureof alcohol use. or to the nature or extent of alcohol problems. An excep.tion was the 11110.1114 that most arrests for illegal delivery occurred in thesejurisdictions with the most rigid control of distribution, no bars, and veryfew package f,tores.lof

Afore study is needed, however, before the effects of these and similarmeasures can be definitely established.

Legal A.ppr( >aches: The Young DrinkersMinimum age laws in the United Starts make it illegal to sell alcoholic

beseiages to persons under the age of IS in some States. and under the ageof 21 in others. In some States, Illinois can chink legally in some instancesat Ili or youngerprovided they think at home, or provided they chink inthe presmce of their parents, or with ',mental consent, or provided they are11131lied.16

.1 here is considerable evidence to show' that these regulations have notbeen and perhaps cannot be satisfactorily enforced, and frequently no)contribute to disiespet t for the law." As was mentioned above, the averageage for the first experience in drinking is reported to be 1'1.

Available evidence from studies in the l'nited States and other countrieswould indicate that the legal minimum di hiking age in itself may not be)f ,great importance. 7 hos, thett, is no minimum drinking age either inItaly, Achich has one of the lowest repented rates of excessive drinking inEurope, or in nante. who, Was one of the highest.

Further light on ihe effect of restrictive lat.es has come from the 111A cstigations by 1)1s. Robert Stairs and Selden liaeon '2.0 on the chinking patternsof college students, ts noted in Chapter 111. In colleges formal pro-hibitions against drinking. relatively few students think, these investigatorsfound. Rut at stub -dry- schools, 'hose students who do drink tend todrink more frequently and mote heavily. and ;ire more often involved indrinking-related incidental problems than are students of colleges with ainore liberal attitude toward drinking.

As a student observed at a college where chinking is prohibited, "lf youhave to drive fifty milts to ,tit a chink, you don't take just one drink.-

Front such evidence. it appe,us that the theory of prohibition nra) soundreasonable but it is destined to failure. It is doomed by the realities ofmanufacture and distribution. In anc f01111 oi another, Aeolic)/ can beeasily produted by .to farmer. by any higleschool themistry student, or bany informed citiitn. It is unrealistic to (Apt t that alcohol can be le um% et1horn use by ,.(xict) simply 1 legistatite fiat.

Religious Appn)achesjust as no legal technique has yet sin«Tded in prc'cnting alcoholism,

religious leaders themselves are among the first to observe that alcoholism

2 53

has not yet been successfully preventedat least in Judeo- Christian cultt aissolely by religious approaches.59 65 126

The attitude of the various religious groups is clear on one point: all arestrongly opposed to e.yressire drinking. 'hitudes toward drinking inmoderation, however, vats markedly belts«, dermininations, and havechanged visibly over the past three or four (ohmic's. Some faiths--notablythe Catholic and Jewish-------hioe always anproved, asccpted or at least tolerated the controlled use of alcoholic bc«,,,gcs. Smile have endorsed the useof certain beveragts Ina hoc of othcls. SevelA Christian den, finanoi -especially since the «illy 1 71./O's----11;he vigorously opposed the its(' fa 1.

in any form.0The National Council of the Chtirc s of Christ, while recogni7ing that

not all its member churches th k alike on the matter of drinking, hassuggested that the presentioh of alcoholism may be related to other socialproblems, and calls for an attack on these other problems by strengtheningfamily life; providing mental health clinics, family service agencies, andpastoral counseling progiams; b) 1 dinoving :huh degrading social con-ditions as had housing, disease, poverty, inadequate education, and poorrecreational and health facilities.

Education: Against AlcolStarting with Vehnont, in 1552. every State in the United States has en-

acted legislation Making -aiming education- compulsory in the publicschools. Since the beginning of this piogiain, tempi ince !cadets havetaken an anise role in hosing the laws adopted ahil in supplying teachingmaterials to the schools): In fiinemi, teaching programs have centered onsuch concepts as these: alcohol is a poison, a isaliotic, and (bleat to 11,;;Iltitand soviet); any alcoholic Insti,,ge is /mislaid: drinking is Minimal: theonly solution is complete alistiminc.`"

Neve" tildes.. inileasing pel«iitatw's of students exposed to these sessionsof alcohol cam:sties' doting the pas( 11,1( imittels or 0 century hate grownup to become adults who think- olotkl:ttion, Sitnifntly, this ua-ditional education ffas not ()ash,. ;hell sfissi.c chinking.

One leason proposer! to ;1,1 1/LIIIL If', dust' blames has been the excessiseemphasis placed on so-cared .e haliniquis.12) Many educators hat . cm-phasiled the dint( laths of riisasters 1111/1\ l(1 itt attempting 10 teach oneset of standards to childrin who hae alleady learned a ditierent set--con-scionsly or unconsciously -flout t1. H ot,n many of whom usealcohol without any apparent &Hoag; t,. fliciuselvcs, and who do not appearto their childless as evil or iiiinsmal.12',

Some educators hase assisted that far,, 1 ,,lye ial on alcohol may helogically pH:seined in die on whether stinking issocially desirable or inotally trptehc nsihle s. 'old he left to individual fmni-lies and their teaching. Some Ifclicse that shout, be ,gist's Lots.induced to discuss pi() ;411'l ( MI .11 '411M( 111s, and! Iht II make their decisionson the basis of information wilif 11 is I..itned in the ,.(lion; Ind in Mu home,together with what is taught 1 their 1,116(411A it li..;ions f;iiill.4''

Accouling to wan) (41nt.i1101,.. the 11;1.11111011A (11111..161MA ;11)1110,11 h bars

failed bemuse it has bc(si cxcessiscit conicanid %%ids .11(011filism, 1,01im

than NVitil the broad subject of chinking. One authority, 1)r. Robert Straus,sass, "It is as if the dritereducation classes in schools would be concernedonly with genier aspects of speeding and reckless (hiving. This mightfrighten a few students, but it would not produce many who know how tohandle an automobile safely. NVith the emphasis placed soldy on alcohol-ism, alcohol education !night similarly (lighten a few students, but it wouldnot produce many who know about chinking, or how to handle alcoholsafely."

Education: For Safe DrinkingThe concept of educating individuals to drink safely or not at all is

scarcely IICW. It is patterned in !mgt.- rut on safety concepts applicabl, todriving and other ac tivities, and is inherent in the habits and attitudes ofthose cultural groups which have demonstiated over many centuries anability to use alcoholic bevelagcs with only a minimum of danger. Implicitis the idea that young people ale given %%flan:ver education possibleinschool, in church and particularly at home- t unable them to understandthat just as it is not necessaty for anyone to chive, it is not essential forhim to drink; but if he does drive or does drink, he should know how todo so with maximum safet for himself and others,

In any such education. it has been stressed, the teaching goals should bethe development, as early in childhood as possible, of attitudes conduciveto healthy and happy living. To ellink or to abstain is a cultural patternwhich, like most folkways, reflects the hinds setting and may he developedby the time the child is ten seals oh1.1.

Among the most important plineiples to he considered ;ire these:I. If is not essential to drink. An nulls idualyouth or adult--who de-

cides to abstain from alcohol for moral, medical. economic or any otherreasons, should not be plated under ptessute to chink by other members ofhis society.

2. Excessive drinking does not indicate adult status, virility or masculitity. In an adult society, one eati no mole establish his manhood by hisability to hold a huge amount of liquor than by his ability- to hold a largeamount of dessert.

S. Uncontrolled drinking or olcoltolicsol is an illness. C161(11(11, isisluslisv4she (hildicn of alcoholic patents, should be awate that alcoholism is not aperversity, not new's:tills a lharalter defect, am! not even the (film iesultof chinking. 'Huy should know that an alcoholic, like a t ictim of diabetesor tuberculosis, is a sick person who can and Should be helped.

9. safe dririkiorg depends me speriftr physlologiral a.c redi as psycho-socialfor tors. These bums include (a) early development of health) attitudestoward chinking, seitilin a strong family enviionment, (h) pre:scallion ofdangerous blood-alcohol lock lit testi lc ling bet cog(' eonsumption to smallamounts, in appropriate dilution. and piefeiably in (olubination xvith food.(c) lc:cognition that diinking is elange ions when used in an cheat to solveemotional problems, and Of unitcisal ,tgleentent that intoxication will notbe sanctioned by the group.

Vast effective is to engender a public attitude that dl inking to the pointof intoxication is socially umu«.plable.

11

11'e should make it clear to [amines, so that they can convey the mes-sage to their children,- sac', 1)r. (;ior,v,io !IM of New Turk, "that leithoutchinking to excess, without ineln let), tittle is no alcoholism . .

5, -in ttnrIcistonding that -Or oho, cello atom" Odoahl idol bc rcsl Yr( 101 to"alcoholism cd to a lion ." Irntcarl, cdtIGItion on :lhollolisin cx(essiechinking should he consideied a> only one phase of edict ;aim! on eatingand (find:nig, ;ind should piefeiabl) be included Is hart of education onnunition and mental health.

To inany workers in this field. the inajot- objectire is the enhancement ofmental health in lanidics and huh% iduals. and the declopinent I suitablesate mechanisms vtlitieb) these families and indir idtials (an sethe their(motional tensions and anxieties.

X. CURRENT ACTIVITIES: SCRVEYSAXI) SERVICES

:1101011g their t.tctiitics hi Re not et telnesented any massive. all -outattack against the 'mildews of excessive chinking. the present opetations ofmail) lttivate and govetnotental agencies at least ,tiggcst thr 1010 c.hichthese agencies might 1,1,1 in the lutine.

Survey of the ProblemTn aS5CSS /he /la(Litt' (ii //it' 011())i+M i)tt))))e/n ;))//1 the TU.SOLITCCS /101V

tiNailat)le to control it, dm National institute of NIcrital Ilealth has sop-pouted the voik of the CatopetittiNc Commission of the tstwil. of ,\lcoholistli,established in coopeiatitin kith the Not th ,untiiittn .\ssociation of .\Icohol-istu 1)rogranls, Vith its Tnotessional stall at the Institute for the Stunt) of

it Startliml leieisit. the (:oopetatic: Commission hadthe lollolving tibjecties: CI) Ti stutl of the scientific kiiciivlecige now auail-able Inith on moclettite drinking and on alcoholism: (21 col 111Noltol!, slut!!'anal oalitation of intpgitints :mod it.sotti«., tIolv ;ottiltible for tin) (cannot of;.tictilnilistin (3) tin imestigmion of Icl;ationsitilts Itetyeen the vations publicand pti%ate ate huh conceinecl NC1(11 ;k1(oholiNtit con-trol: (I) the incitowictil 111 tc(outntcnd:atir for il»1»-tA uthit ,

1)1 (.111H11: ;ill (1 (7/) ,,j,(111:1;11 1(111, for 11.

In t1/(1111e1 N1 N1 1-,11)/1 /01 1(1 /1(1111:1. (0111111( Ird in l(1,01)1_1:111,111 1V1111 the1)iision of Alwholic Rchabilitltion llepaittiorn of Public

in%estigatots itaot hcgtlil to ilic:Isuic ihc 1;t1( ;it whit]);11(1)11(di,111 Appc,11 ;11111h11] ill sclectctl pOnli1:164)II groups. Vbile 11':11

1.111111,111!_!, piticalcs thAtIointicrit of tilcolodism, not all ficaN ihinkels((MI( 1/1 1111/11/1l Rt,t'd11 1, 1111(1(1 \ to 1111(1 out '111V 111;111% /10 1/c/ 011TH

;1. /11P1110, ;11111 II/ dent Mitt(' 11111,1' Lit (01 that 111,1% lit h oI theLens (Irinkcts 1611 t fillit( it (I.

171 'ht. pilot (.,11110ttiti ,111,15.1 51 it 111111/ ,:11rlid111g tcthnnIuc 55;15 111-1 C1-

111f1 11,1:11 /1/ 111/( / 1 11%1 /111! 11(11,' /11,111 1,11110 ,111)jci is in 11//, tii-t1sto area 19/1.!.c. Alust it Iht,e 1/1(111 1t111.11, acn 11111:1 1V1,11 i1,2.1//1

111 191/:i ;11111 191/ 1 111 an ant,npt Is ..ic.isnic s in di habits.Mc.piishilt., itlitcd 511(15 ilt.,.lopcit is

till h5 51 it ini51, .0 (a w!-;(- \\ rinN(l'ilN. in VI'll-itit;tuii. and is oiling 41 it stmt ..ppto\Jima 101 11,)11.1 ILL t 's1.111

A1111111( in\ tsti2ition, not rift(' to miasmic not the tfa.o1 ts in the nu wbcr of ,cf.o1iiiIits hot lino ],iic.111niI tut uu111111 Itti 1,1100 ptIpttrAinti

"1" on " I I i "TV" / 111C ighlI 11(.11th Iti,tit I ttl tht CtiN tt lo the It wed, nt.til 1.0(0lies 5,c It' CIO( 64,1 Alert health looldt intlitdite4 into\i(non. wid tilso shoot loft old wont I Illo1/1/ 111,, 1,111111 \ art unt.nts and

16 k;

violence, marital break-ups, neighborhood troubles and "difficulties with thelaw" which might be connected with excessive drinking. The preliminarydata have Makatea an overall alcoholism prevalence rate of 19 per 1,000,with a ratio of 3.0 men to I woman.

In still other projects, mans: of them supported by State or Federal funds,similar surveys MC hieing conducted on the drinking patterns of teenagers,Negroes, and Indians, Spanish - Americans, and Anglo Americans in the

Southwest; and, in Sweden, the drinking traumas of alcoholics, normaldrinkers, and former drinkers who have heroine abstainers.

Previous research on the drinking patterns of various cultural groups,both in this count.): and abroad, has revealed cultural characteristics whichseem to be F.gnificantly related to either safe or dangerous drinking prac-tices. It is expected that further investigations in this field will increaseknowledge of the prevalence of alcoholism within specific cultural groups,and also add to the understanding of some of the causative or protectivefactors involved.

Treatment and Rehabilitation FacilitiesReduction of Me problem of excessise chinking must come about pri-

i. irily from increased orevention. The selions sinnition of those who arenow alcoholics. licni:evet, cannot be ignored.

To date, the treatment of stub drinkers has been largely the responsibil-ity of individual dui:Tisk physicians, rlcr,gyrncn. .1.1 workers, socialworkers and others_ -using State hospitals. clinics and other finililies. Fed-eral support has plus ided tclhnfcal ,issistati«, and «msultation in piogramdevelopment, the planning of muiptchensise mental itcalth 1)1 ogt anis. the

mJliiiiration of community. personnel :Intl facilities, the development ofnew and improved community health services, and the consittiction andstaffing- of community mental health «Awls.

In certain instances, the Fednal Goscinment has taken all active role inthe demonstration and testing of new techniques of tteatment. For exam-ple, as a demonstration project iu cooperation with the county health de-

tnient, NINIII has helped to initiate a county-wide alwholisni programin Prince Georges C:onnty, Maryland, all ni ban.subtil ban-rural area adja-cent to 11'ashington, 1)csigned as a plibl;e. health approach to theproblems of alcohol, the project is aimed at: (1) developing a comprehen-sive program to rehabilitate the alcoholic as well as his family, utilisingcombined community facilities: (2) developing cdiaational activities to re-duce the stigma of alcoholism, stimulate curls diagnosis and treatment, andaontrilmie to the prevention of the disease; and (3) olcoiporating measur-ing devices into the piogram to determine the efficacy of particulartechniques.22

At Saint Etizal)ohs Hospital, operated by the Federal Government inNVashington, 1).C., a new unit has been established to inoside a coordinatedtreatment and lebabilitation plogram for alcoholics, utilising group ther-apy, vocational training and other techniques for both short- and long.-tomtrea intent.

Another NIMIl. supported demonsnation project is located at lkfalcolinBliss Mental Health ( :enter in St. Louis, Missouri, yekere a community.-

.17

centered treatment program is being developed for alcoholics, statting svithinpatient treatment in the hospital and extending through systematic refer-ral cooperating agencies in the community. Attempts are being made todetermine which patients can he most effectively rehabilitated throughhospital inpatient and outpatient services, and which should be referred toother community agencies.

Typical of somewhat similar activities in a number of States, the Geor-gian Clinic in Atlanta is utilizing State support to provide both inpatientand outpatient service Jot alcoholics, and Federal support for demonstratingand testing night-treatment facilities for alcoholic patients tho are able towork during the clay.

As part of its activities in providing financial aid and professional leader-ship in rehabilitating patients with all types of mental or physical disabil-ity, the Vocational Rehabilitation Administration supports vocational coun-seling as part of the treatment of alcoholics. The Welfare Administration,working through State and local welfare departments, is able to providepublic assistance payment for families of alcoholics who are unable to sup-poi t their chihlrell, or who desert them. Some individuals, disabled becauseof their addictive drinking, are qualified to receive aid provided for thepermanently and totally disabled. Medical care programs help indigent;11(011014s and their families, while social welfare services are available tohelp the alcoholics and especially their spouses and children.

Afally alcoholics have been aided through these and similar got eminent-supported treatment and rehabilitation piogiams. lint the number of pa.thins requiting this kind of help has been estimated to be in the millions.

Community Mental Health CentersThe treatment and control of alcoholism has a major relationship to

mental health services. As community mental health centers develop theirservices to provide a continuity of one for individual patients, treatment ofalcoholics will be included within the range of their comprehensive'nog! ants.

Sonic mental health collets will be mg:mired to treat alcoholics andother patients in a totally integrated ',Iowan'. Others may provide partiallyintegiated services for all patients, while providing additional servicesadapted to the special needs of alcoholics. A third opcnational plan wouldprovide it totally differentiated service program for alcoholics within thecenter.

The degree to which ;1 mental !mild' toner can help to solve a commu-nity's alcoholism piohlem will be determined to ;1 large extent by theamount of public suppoit the Centel receives. Thus, as the ccnteas are estab-lished, it will be their gadin addition to ',unman of patientsto informand educate the citimity and some suong community support for thetreatment of alcoholics and then families.

Technical TrainingTypical of tiaining actisities for professional workers is a threeleat

demonstration project sill/potted by NINI 1 I at the Nebraska Psychiatric In-stitute, Omaha, and ;dined at demonstiating new was of providing special

J9IS

psychiatric training for general practitioners. Thirteen small-town familydoctors traveled to the Institute at monthly intervals for a series of 2-Itraining sessions. In the first year after training, they used their own officesas outpatient facilities in the treatment of 159 alcoholicssome referred bywives, husbands or other relatives, and some coming on their own initiativeto seek helpas part of regular family medical care.

Significantly, the specially trained family physicians soon found theywere called upon to speak to their medical societies and other groups onnew developments in the treatment of alcoholism. Of at least equal signifi-cance, a follow-up study showed that the special training invested in thesephysicians had long-term benefits: the treatment of alcoholics remained anaccepted part of their routine medical practice.

With both State and Federal support, a variety of related training pro-grams has been instituted in Missouria project for family doctors andother health personnel at Washington University, St. Louis; a treatmentcenter serving as a model for rural public health workers; and an inservicetraining project which has aided in developing effective working relation-ships among therapists, police officials and court personnel. Similar supportin other States has provided for the training of general practitioners, psy-chiatrists medical residents, nurses, social workers, psychiatric aides andchaplains. One such project in Atlanta has made possible a training pro-gram not only for medical residents from local hospitals but also for gradu-ate ministerial interns.

Included in the training activities have been two- or three-day workshopsor conferences to aid in postgraduate studies, and week-long training insti-tutes sponsored at colleges and universities.

Of particular value is oject supported by NIMII at the Center ofAlcohol Studies, at Rutgers, to bring some order to the currently confused--and confusingterminology in the field of alcohol, drinking and alcohol-ism. Another is preparation of an American Public Ifealth Associationguide for the public health control of alcoholism.

Training programs also are sponsored by the Welfare Administration, theVocational Rehabilitation Administration and the Office of Education.Thus far, all these salamis programs haw provided valuable speciali/edtraining to many hundreds of health workers. Thousands more, however,must be trained to staff progiams for time inevention and control ofalcoholism.

Community Education and OrganizationOnly a start has been made in imptosing the «miumnication to the gen-

eral public of available knowledge on alcohol, chinking and alcoholism,and the otganization and the molnliiation of local facilities are only begin-ning. In the developments which have occulted thus far, an important rolehas been played by snarly coluntaiy oip,aniiations such as the Rutgers Cen.ter of Alcohol Studies, the National Council on Alcoholism and variouslocal Councils and mental health associations. as well as by govetnmentalagencies, which have helped to provide information and stimulate publicaction during the past two decades.

Sonic possibilities for future activities are already apparent. For example,

GO99

an NINIFIsupported project at Mississippi State University is directedtoward school administrators, classroom wacheis, students, parents, religiousleaders, law enforcement officers, city officials, public health personnel andhospital administrators. It is intended to explore the possibilities, limita-tions, problems and values of a comprehensive alcohol education programto find who does not want alcohol education, and why not, and whodoes want such education, why and what kind.

At NVestern Reserve University, in Cleveland, another project is directedtoward community education, comtmmity information, and communityorganization, involving internists, psychiatrists, clinical psychologists, socialworkers, nurses and clergymen.

In the Michigan Upper Peninsula, a large rural area in which only lim-ited resources base been available for the treatment of alcoholics, the Alco-holism Program, Department of Public Health, is engaged in an NIMI-1-supported project to have alcoholism accepted by local communities as atreatable illness and to stimulate the utilization of local resources for itstreatment.

Similar projects, some with State support and sonic with Federal support,have been instituted in scores of other cities and other local areas. Thenumber of communities in which such programs are urgently required,however, is estimated to number in the thousands.

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50

XI. CURRENT ACTIVITIES: LABORATORYANI) CLINICAL RESEARCH

In the future, it may well be that the greatest impact will conic not fromexpansion of present services but from basic and applied research.

During the past several years, support for such research has already beengiven by various parts of the Federal, State and local governments, and byvoluntary organizations and industry, inchnling the American Heart Asso-ciation, the Board of Christian Social Concerns of the Methodist Chinch,the Ford Foundation, the Nutrition 1:mutilation, the Christopher D. Smith-ers foundation, and the United Health Foundation. It has also been givenby the Licensed Beverage Industlies, the United States Brewers Association,and the \Vine Advisory Board, an agency of the Califonlia State Depait-ment of Agriculture.

Among the cooperating institutions, perhaps the largest, oldest and mostinfluential is the Center of Alcohol Studies, located at Yale University from19.10 to 1962, and since then at Rutgers Univeisity. It has been a center ofresearch, education, postgraduate c;iining, demonstration, documentationand publication, and its Quarterly Journal of Studies on Alcohol is re-

garded as the most authoritative in the world. Starting with laboratorystudies on the physiology and metabolism of alcohol, the Center's workershave pioneered in objective icsearch on chinking, on traffic safety, and onalcoholism.

Examples of some current investigations are indicated in the followingsections.

Effects of AlcoholEssential for an understanding of the actions of alcohol in excessive

drinkers is further knowledge of its effects in moderate drinkers. Accordingly, scores of investigations are being conduced with private or governsmint support on the metabolism of alcohol, its actions on enzymes, tissuesand organs, and its behavioral elicits in human subjeits and in animals.Much of this new ieseaull has been made possible by the utilization ofbiochemical, pharmaiological and clecturpliysiologic al techniques and in-sights which were IlllavaiLildc ten or fifteen years ago.

Some studies, for example, indicate that the elicits of alcohol ate notnecessarily related simply to the alcohol contestation in the Woad. Forinstance, scientists at the Katohnska Institute in Stockholm have suggestedthat skilled performance may be impaired it a certain level when theblood-alcohol curve is rising but there may be no impahment at the verysame level when the blood akohol (Wye is falling:4 An individual maythus be judged intoxicated at niter bloodalcohol les el when the (lute

6251

is going up, but sober at the same level when the curve is going clown. Inthe same field, research in the International Center for Psychodietetics hasindicated that identical blood-alcohol levels in the same individual can beassociated kith remarkably different psychomotor pet formances, dependingon whether the individual consumed the alcoholic beverage with or withoutmeals:76

At Boston City Hospital and other centers, investigators have observedthat some alcoholics brought to the emergency r00131 in a state of comausually after the ingestion of large amounts of alcoholmay not havepat ticularly high blood-alcohol levels but do have extremely low blood-sugarlevels. A similar result has been produced its normal volunteers who haveingested large amounts of alcohol on an empty stomach. Apparently, theinvestigators conclude, a large dose of alcohol taken by an individual whohas been fasting for 21 110111S 01 more can produce a rapid, dramatic (hopin blood-sugar concentrations and, in fact, can cause the so-called hypogly-cemic coma similar to that produced by large doses of insulin. The alcohol,it seems, prevents the liver from manufacturing and releasing sugar into thebloodstream in the normal way, and the normal homeostatic IIICChalliSMSwhich protect the body from low blood-sugar levelseven during periodsof stm vationstop functioning.41

In another study conducted on human subjects strider an N1MH projectat the University of California at Los Angeles, it has been found that alco-hol increases the abundance of alpha-wavcs in the !main as measured bythe electroencephalograph, with a tendency toward the production ofslower rhythms in the alpha range. The effect, which is related to theamour t of alcohol ingestcd, may ram the sedative or tranquilizing prop-erties of alcoho1,I

From these and many other investigations, it is obvious that much moteresearch must be done before the phannacological effects of alcohol uponbehavior in animals and in man are adequately understood, in terms ofeither the primary effects of alcohol on the central nervous system itself orthe secondary effects of alcohol upon behavior.

Physiological Factors in Alcoholism

Another large body of rose: tch is concerned not directly with the phar-macology of alcohol itself, or the effects of alcohol on normal subjects, butwith the actions of alcohol in alcoholics and with any chemical. endocrino-logical, neurological, and other physiological differences which may existbetween normal (trinkets and alcoholics.'n

Inning the past few yea's, such investigations have been performed onnerve C011d11(11011 amid the functioning of the sympathetic nervous system inalcoholics, dub :imino acid and vitamin balance, and the activity of vari-ous enzyme and horinone systems.

Particular attention has been paid to the rate at which alcoholics metabo-hie alcohol in dill-emit forms and mulct different conditions. Sevetal inves-tigations have teve;dcd, for example, that alcoholics may metaboliie alcoholsomewhat fasterabont 10 or 20 potent more rapidly- -after prolongedalcohol ingestion. Stich an obscisation has milked in the suggestion that

52rl a

continued ingestion of alcohol might lead to an increased production ofthe enzymes necessary to metabolite alcohol. Confirm-anon of this belief hascome from a recent study supported by NISI 11 at Massachusetts GeneralHospital, where investigators found tinder controlled conditions that con-sumption of reiatively large amounts of alcohol for a I-1-day period willgive an increased rate of alcohol metabolism in both alcoholics and normalsubjec ts .93

Under these conditions, it was observed, both groups also ',bowed anincreased production of cortisone, the ach.enal hormone already known toincrease enzyme activity in other biological systems. It therefore appearsthat continued drinkingin either normal subjects or alcoholics--leads toincreased cortisone output, which in turn leads to increased activity of theenzymes which metabolize alcohol.92

From the Massachusetts General Hospital study, it was also learned thatthose subjects who manifested the greatest increase in cortisone productionduring the heavy drinking period were those who also demonstrated thegreatest increase in the rate of alcohol metabolism. In general, the alco-holies showed a much greater cortisone response during the drinking periodthan did the normal drinkers. Even when the drinking period was termi-nated, the alcoholics continued to increase their cortisone production.

In the alcoholics, it was felt, this cortisone production seemed to be partof a general reaction to alcohol comumption. It was associated with increased anxiety during the drinking period, and perhaps with the laterwithdrawal symptoms.

In the normal drinkers, elevations in cortisone production seemed to beassociated primarily with gastric upsets and stomach irritation caused bythe excessive drinking. These subjects did not show the general, sustainedinn ease ire cortisone production observed in the alcoholics, and they didnot manifest severe withdrawal symptoms when alcohol administration wasstopped.

Alcoholism in Experimental AnimalsFor more than a decade, much effort has been expended to produce,

preferably by simple procedures, alcoholism in an animala laboratoryversion of the human disease which might greatly facilitate research oncauses, treatment and pres(1111. These attempts have not been successful.

Government-suppon«I research at the University of California, theScripps Clinic Research Foundation in 1,a Jolla, California, and the Hill-vetsity of Nor th Carolina has led to the discovery of inbred strains of micewhich demonstrate a selective preference for alcohol and drink it in largeamounts. This prefetence is genetically' determined, and is not affectedeven when the young mice of these strains ate raised by mothers of a diflercut strain, or exposed to various conditions of stress or isolation. The miceof these heavy-drinking strains, however, also happen to be able to 'limboline alcohol much mote rapidly than are mice of other strains; acceodingly,it is impossible to determine whether their increased alcohol intake is re-later! to a particular doh(' or to their ability to consume mole alcoholwithout becoming intoxicate:1.113

64 55

Another study has indicated that an apparent desire can be induced inrats by first injecting minute quantities of an alcohol solution directly intotheir brains, every' two or Mice hours for several days, through a speciallyimplanted cannula or tube. Thereafter, it was found, the rats will takealcohol by mouth (vIrenever it is offered to thern.98

Until the last few years, little work in this field had been done on thecommon rhesus monkey. Now preliminary NIMIIsupported investigationsindicate that it may. be a particularly useful laboratory animal for alcoholresearch.

At Massachusetts General Hospital, for example, a study has shor:n thata rhesus monkey can develop a pattern of heavy drinking when exposed toperiodic stress for prolonged periods. In this case, the investigators found,the monkey ma)' continue the heavy drinking pattern after the stress isterminated--a situation which may resemble that in which a hard-drivingindividual drinks first to relieve stress, and then develops a drinking pattemwhich continues even without stress:A

At the University of Michigan, other investigators have studied rhesusmonkeys with an apparatus which the animal can use to give himself aninjection of a drug through a pennanentlyconnected intravenous catheter.With such a device, it had already been found that monkeys will learn toself.achninister such agents as barbiturates, cocaine, morphine, and am-phetamine.9 These techniques arc currently being used to study self-administration of alcohol in monkeys.

"The rhesus monkey may yet provide an ;.ininial experimental model ofhuman alcoholism," it has been stated by Dr. Jonathan Cole of the Na-tional Institute of Mental Health. "However, investigators may be faced, asthey are in man, with identifying the differences between monkeys wholike large quantities of alcohol and monkeys who are teetotalers or onlyoccasional indulgers."

Research on Therapeutic MethodsOf most immediate practical value are research projects on different

aspects of alcoholism treatment. Some of these are conceited with studiesof the management of patients in the offices of private practitioners, half.way houses, clinics and hospitals. Others are directed toward the develop-ment of new and more useful therapeutic drugs.

In these investigations on therapeutic methods, it has been emphasi/edthat dare ale a immix' of different clinical states which must be attacked.These include: (1) acute alcohol intoxication or severe drunkenness, (2)alcohol withdrawal s)mptonis short of delirium tremens, (5) delirium tre-mens itself, (4) other ps)chhatic conditions associated with alcoholism, suchas alcoholic ballini»osis, and (5) the long -term problem of addiction.

In the past, failure to consider these conditions separately has resulted inmuch confusion in the anal)sis of therapeutic revolts.

In the treatment of wite alcohol intoxication, research has thus farfailed to yield any phanuawlogital agents with significant value. Varioustranquiliring (hugs have been tested, but the evidence of their usefulnessis generally inconclusive.

54 65

In the treatment of withdrawal symptoms short of delirium tremens,many investigations have indicated that such tranquilizers as promazine,chlordiazepoxide and diazepam may be valuable. Such drugs can apparentlyserve to reduce the tremulousness, anxiety, sleeplessness, nausea and generaldiscomfort which mark this condition. But it has not been established thatthey are substantially superior to older sedative agents such as paraldehydeand chloral. hydrate.12

Here, a major problem has been finding a suitable technique for measur-ing the value of the various treannents. Sonic investigators have sought touse the degree of tremor or shaking as an indication of the severity of thecondition. Others have attempted to use clinical ratings of anxiety, tension,discomfort and insomnia, or subjective self reports from the patients them-selves. No technique has so far been found widely acceptable.

In the case of delirium tremens, a serious and sometimes fatal condition,tranquilizers base also been described as highly effective but there is noadequate evidence that any of these agents is markedly superior to paralde-hyde. Other studies have shown that intensive nursing care, and propercontrol of the patient's food intake and his electrolyte balance, may beeven more important than drug therapy in preventing death. Earlier re-ports suggesting that administration of cortisone or ACTII could shortenthe course of delirium tremens have not been confirmed.

The cause or mechanism of delirium tremens remains poorly understood.From work done several years igo at the Addiction Research Center, U.S.Public Health Service Hospital, in Lexington, Kentucky. and a recentNIMII supported investigation at Nlassachusetts General Hospital, it ap-peals clear that the phenomenon of delirium tremens is not simply a directtoxic effect of alcohol on the brain. In fact, it usually occurs after alcoholwithdiawal--in individuals who have been consuming large amounts ofalcohol steadily fur many clays or weeks, and svho then stop drinking.

Even less understood is the phenomenon of alcoholic hallucinosisamore chronic condition than delirium tremens, usually marked by auditoryhallucinations but without the disorientation and panic seen in deliriumtremens,

In the fongferm ircabnclit of alcoholics, once they have gone throughthe acute withdrawal stage, drug therapy has not proved to be of markedvalue. At the University of California at I.os Angeles, trials have shownthat tranquilizers are usually little better than placebos in thei: longenneffet ts..12

During the past fess' Yeats, clinical research interest has been expressednn several totally diffeient pharmacological approaches to the ticatment ofalcoholism. One of these involves the use of lysergic acid diethyl:nnide(LSD 25), which induces stiange and txcasionally in)stical sensations andexperiences. Sonic patients tepoitedly emerge from such experiences withgreater insight into their problems and considerably enhanced motivationto abstain from almhol.121 The findings appear to be highly controversial,and the dtnabiilty of desired changes in attitude is yet to be detennined.Further studies of these icactions are being undertaken with NIMIIsupport.

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The foregoing examples, it must be mphasired, do not comprise acomplete sun'ey of all research and SC1Vice projects on alcohol, drinkingand alcoholism now underway. They sers only to illustrate some of themajor topics which are curren ily under scientific investigation. They rep-resent only a beginning.

Some of the major objectives yet to be achieved are indicated in thefollowing chapter.

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XII. FUTURE NEEDSIn alcoholism, as in the case of such cliseaeY as cancel, schizophrenia

and even many types of asthma, the fact that th- cause is unknown orpoorly understood does not mean that medicine is powerless tc help thepatient.

As noted in earlier chapters, experienced therapists believe that methodsalready known and tested in the treatment of alcoholism could providesubstantial help now for many hundreds of thousands of patients. The full-scale application of these techniques, and the development of better onesrequite the mobilization of many community resources.

Application of Present KnowledgeFor the preliminary treatment of alcoholics in the acute stage of intoxi-

cation or in delirium tremens, it has been eemonstrated that care in thegeneral wards of general hospitals can be safe, economical and effective.Many hospitals, however, are still reluctant to accept such patients. Physi-cians therefore have recommended these objectives:

Alcoholic patients should be admitted as their clinical needs indicateby all general hospitals.All hospitals should be equipped with whatever modem drugs andother facilities are needed for the treaty ent of patients who arein,cxicated or suffering from delirium tremens,Suitable advance training and orientation in the care of alcoholicsshould be provided for staff physicians, nursei. attendants and ad-ministrative personnel.

These are primary needs, hospital and medical leaders have stated. Hospi-tals will meet this responsibility when it is required of them try thecommunity.

For long-term psychotherapy and rehabilitation, treatment in the handsof physicians, AA workers, clergymen, p,,ychologists, psychiatric socialworkers and other professional per.-..onnelworking alone or in teamshasbeen shown to be effective. Here these needs have been indicated:

The requirement for mental health centers, clinics, longtenn inpatientcare and outpatient facilities in each area should be determined andessential facilities provided by pis ate and governmental agenciesfor followup and long -tent 3elrabilitation ca t e, and special nighthospitals, day hospitals and halfway houses for temporary inpatientcare.

ID Training in the treatment of alcoholics, now offered by only a fewmedical schools, should be taught routinely by all medical schools.Appropriate education should be provided for clergymen, public

68 57

health workers, social workers, teachers, psychologists, nurses andnursing aides.Special courses should be made available for physicians and otherprofessional personnel already it practice, as well as for lawyers,judges, police officials, AA workers and others who may be workingwith alcoholics.Appropriate textbooks, pamphlet!, audio-visual materials and otherteaching aids, based on objective knowledge must be prepared.For such teaching purposes, as well as for general communication inthis area, at least a tentative we rking agreement must be reachedon vocabulary and terminology.Intensive, controlled studies on the various types of treatment nowbeing used should be conducted to measure their relative efficacy,and determine tl!:: types of patie Its for which each is most suitable.Employers, personnel experts, soc'al workers, marriage counselors, lawenforcement officers, and other key individuals should be trained todetect early signs of possible z-lcoholisin so they can recommendappropriate referralsFurther efforts arc needed to improve both communication andcooperation among professional and lay groups interested in alcohol-ism, and within such groups.Control of excessise drinking must be included in communityhealth program planning, and fragmented health services must beconsolidaced.

[fere, too, the public has a major interest. Such activities may be costly,but they will cost the taxpayers less I Iran attempting to salvaw the damagestemming from uncontrolled alcoho'ism.

Search for New KnowledgeTo develop better techniques for treatment and for prevention, these

urgent needs must be met:

More effective drugs are required for the treatment of intoxicationand delirium tremens.Effective drugs or other thera3eutic aids must be developed for thesafe, rapid alleviation of har gover, if only to break the drinkingcycle of many alcoholics who 'mew their alcohol ingestion as a self-treatment for hangover symptoms.Better :Ind non-addicting dru ;s should be developed for the reliefof emotional tension and for ,iossible use as temporary or lo.rg-termsubstitutes for alcohol.In order to speed the des elo, )Hunt of such agents, and the studyof the disease in general, it is essential to find a simple method ofreproducing alcoholism in exp uinrental animals.Further studies are needed on the effects of alcoholic beverages (andnot merely alcohol) on the brain and other organs.A further search should be n ade for any chemical, physiological,hormonal, metabolic or other basic constitutional difference which

58

may exist between alcoholics and normal drinkers, and which mayaccount for addictive drinking.More information should be obtained on the effects of specific foodscarbohydrates, fats and proteinsin protecting against dangerouslyhigh blood-alcohol levels.Long-term studies must be made on large numbers of human sub-jects, beginning early in life and continuing for many years, todetermine the chemical, psychological, sociological or cultural fac-tors which might be related to the development of alcoholism.Better techniques should be developed for one-to-one and grouptherapy.

For basic research aimed at prevention of alcoholism, and capitalizingon the discovery that some cultural groups seem to have a built.in pro-tection, the following are required:

Nationwide epidemiological research is needed to describe and meas-ure the problem; to replace present vague estimates and impressionswith statistically significant, tip-todate infonnation on the drinkingpatterns of Americans; on the numbers and characteristics of moderatedrinkers and of alcoholics; on the actual size and costs of suchproblems as alcoholism in industry, drunkdriving and excessivejuvenile drinking; and on any changes which may occur as theresult of control efforts.Reliable methods are needed to measure the numbers of alcoholicsin specific geographical areas, vocations, races, age groups, and othersocio-economic classifications.More detailed studies are needed on the major low-incidence andhigh-incidence cultural groups, to determine differences which maybe significant as protective factors.Analysis is needed on attitudes associated with dangerous drinkingon the one hand and with safe drinking on the other; and develop-ment of methods of influencing or modifying such attitudes amongchildren and adults. Considerable research must be focused onchanging or improving the attitudes of parents toward drinking sothat they will wisely guide their children's experience with alcohol.

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59

XIII. THE NATIONAL PROGRAMTraditionally, major governmental responsibility for the control of

alcoholism Las been assumed by the States and local communities, usuallythrough their mental health or public health programs. On such activities,during the early 1960's, these agencies spent between roughly $15 and $20million a year. Various Federal agencies provided some collaborative as-sistance in these control programs, and furnished support for a limitedamount of research.

Beginning in 1966, the Federal Government joined in a full partnershipwith Statc and /oral organizations, public and private, to develop a unified,coordinated program of control and prevention based on a nets' nationalpolicy in which the gravity of the problem was fully recognized.

The Presidential DirectiveIn March 1966, in his Health Message to the Congress, President Lyndon

B. Johnson called for the start of the new program. tie said..The alcoholic suffers from a disease which will yield eventually'

to scientific rearch and adequate treatment. Even with the presentlimited state of our knowledge, much can be done to reduce ihe untoldsuffering and uncounted waste caused by this affliction. 1 have in-structed the Secretary of Health, Education, and 'Welfare to appointan Advisory Committee on Alcoholism; establish in the PublicHealth Service a center for research on the cause, prevention, controland treatment of alcoholism; develop an education program in orderto foster public understanding based on scientific fact; and work withpublic and private agencies on the State and local level to includethis disease in comprehensive health programs.

The Health, Education, and Welfare ProgramThe President's directive speeded planning which had alle,dy been

underway vvithin the Department of Health, Education, and Welfare.The expanded program was organized during the next few months, andformally announced in October 1966. Centered in the Department ofHEW, it has set two main goals to be attacked simultaneously. One isimmediate: to make available the best treatment and rehabilitative serv-ices to those who need them now, through the mobilization of existing re-sources and the pro ruction of additional health manpower and health bell-itics. The second is long-range: to develop effective, practical and acceptablemethods of preventing alcoholism and excessive drinking in all theirdestructive forms, and to develop ituprovect therapeurk techniques.

In order to achieve these objectives, a broad departmental policy wasenunciated by John W. Gardner, Secretary of HEM', to hig'ilight thesepoints: 7160

Improved coordination of the alcoholism activities of the Depart-ment's coDstituent agencies.Fostering of closer relationships, improved communications, and othercollaboration between the Department and non-Federal groups inter-ested in alcoholism.Creation of a national action policy, based upon an awareness thatalcoholism is a treatable and preventable disease.Development of broad-based, multidisciplined, integrated intramuraland extramural programs of basic and applied alcohol research anddemonstration.Development of a program of education based on sound, scientificfacts ft.,r the health professions and the public on drinking andalcoholism.Development of means to enable States and local communities toutilize effectively' botit existing and new private, public and voluntaryagency resources in the development of comprehensive servicesmedical, social welfare, vocational rehabilitation and other thera-peutic, preventive and supporting measures -to meet the needs ofalcoholics and their families,

Intragovernmental CoordinationTo improve coordination within the Department of HEW. an internal

committee established originally in 1964began intensifying its operationsearly in the spring of 1966. In this group are representatives of the Del fit-ment's major operating agenciesthe Public Health Service, includingespecially the National Institute of Mental Health; the Office of Educa-tion; the Vocational Rehabilitation Administration; the Welfare Admin-istraticn, inclucr.,g the Children's Bureau; the Social Security Administra-tion; the Food and Drug Administration; and Saint Elizabeths Hospital.

Chairman of the internal committee is the Assistant Secretary for Healthand Scientific Affairs.

By the summer of 1966, informal liaison was established hetween thiscommittee and !,prescntatives of the Veterans Administration, the CivilService Commission, the Department of Commerce, the Department ofDefense, the Depattnient of Justice, the Department of Labor, and otherbranches of the Got etnntent which were likewise deeply concerned withone or more aspects of alcoholism rontrol.

National CoordinationTo imprcue coordination between governmental and nongovernmental

agencies, a National Advisory Committee on Alcoholism was appointed bythe Secretary to give advice and guithrne on broad long-range policies,help speed the disserninatron of inform:nicht quickly and 4ccurately be-tween all major interested group, in the field, and prevent needless:replication of overlapping of rtforts.

Included on the committee are 18 representatives of medicine, socialwork, labor, industry, vocational rehabilitation, education, hospital groups,the law, the clergy, and voluntary agencies.

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National Action PolicyTo mobilize existing resources and existing knowledge for the care of

those already afflicted with alcoholism, the policy enunciated by theSecretary called for a number of steps based on sound medical and socio-economic principles.

Among the recommendations were these:

to Hospitals, clinics, nursing homes, and medical centers should beencouraged to admit and neat alcoholic patients routinely as theirmedical needs indicate.

to Physicians and other health scot kers should be encouraged to accept,treat and counsel alcoholic patients within the limits of their pro-fessional competence.Within the framework of their respective functions and responsibili-ties, health, education and welfare agenciespublic and pivateshould be stimulated and encouraged to provide necessary servicesto cope with the problems of alcoholism.

* Public and private insurance carriers should be encouraged to in-chide the treatment of alcoholism in health insurance policies.

In addition, the DHEW policy statement called upon the Federal Gov-ernment to take a responsible position for those of its own employees whomight be alcoholics.

The Federal Government, as a major employer, should recognizealcoholism as a medical problem which may seriously concern someof its employees and therefore itself; {it) should include its pre-vention, control and treatment in employee health programs; and(it) should, therefore, recognize alcoholism as a justification for dis-ability retirement.

ResearchIn accordance with the President's directive, the new National Center

far Prevention and Control of Alcoholism has been established in theNational Institute of Mental Health, now a major bureau of the PublicHealth Service,

In addition to carrying other responsibilities, the Center is serving asthe focal point in the Public Health Service for basic and applied research,training. demonstrations and technical assistance to non-Federal agencies.Some cf the investigations supported through Federal financing are intra.mural, conducted within the Center or other sectors of the Department ofHEW, while others are extramural, carried on in universities, medicalschOols, hospitals, clinics, and other appropriate research centers, by meansof research grants or research contracts.

Additional research and demonstration programs are being supportedby tI c Office of Education, the Vocational Rehabilitation Administration,the 11'elfare Mminisuation, the Food and Drug Administration, andSaint Elitabeths Hospital. Close liaison has been established to coordinatethese programs with special research and demonstration projects supportedby other governmental agencies.

62

EducationTo provide objective, unemotional, accurate information on drinking,

and on alcoholism, key toles have been assigned to the Office of Education,the Public Health Service, and the Children's Bureau of the WelfareAdministration for the preparation of appropriate and coordinated educa-tional programs for the general public, and especially for school-agechildren, college students and their parents.

Similarly, these agencies and the Vocational Rehabilitation Administra-tion have been assigned responsibility for the development of coordinatedprograms for the training of health workers including physicians, nurses,rehabilitation counselors, social workers, hospital technicians, and clergy-mento enable them to provide needed services in this field.

The production of informational material by the Department is beingcoordinated with the work of major nongovernmental organizations whichare engaged in preparing similar materials.

Delivery of ServicesRecent legislation has made it possible for several of the Department's

agenciesnotably the Welfare Administration, the Vocational Rehabilita-tion Administration, and die Public Health Serviceto aid State and localagencies in providing needed care to alcoholics and their families.

In the case of the Welfare Administration, programs are being developedin cooperation ivith State and local welfare agencies to help maintainfamily incomes, furnish social welfare services, and provide payment formedical care and community organization activities for alcoholics andtheir families.

Under the new Medical Assistance provisions (Title XIX) of the SocialSecurity Act, necessary medical care can be financed in certain States forthose alcoholic's who can be classified as medically indigent. Ordinarily,under this legislation, treatment in a mental hospital is not covered.

In the Vocational Rehabilitation Administration, increased funds arcbeing assigned for the provision and expansion of services by State rehabili-tation agencies, the development and introduction of new rehabilitationtechniques for alcoholics, the construction of rehabilitation facilities, andthe support of workshops.

In the case of the Public Health Service, major interest has been focusedon the new Comprehensive Health Planning and Public Health ServicesAmendments of 1966, which are believed to represent the best vehiclefor the rapid development of adequate cace of alcoholics. Under this legisla-tion, comprehensive grants can be provided to each State to bring healthprograms in line with the existing health needs of that Sta;e. In thoseStates and communities in which alcoholism is recognized as a majorpublic health problem, these comprehensive grants would offer the great-est opportunity for efficiently coo-dinated Federal and State action.

Other recent Federal legislation makes it possibt, to provide financialsupport for training professional and 'nonprofessional health workers totreat alcoholism, and for constructing necessary hospital, clinic, and cont.munity mental health facilities.

In describing the new program, the Department of HEW has emphasized

74 63

the pressing need for coordination of all research, treatment, prevention,training, education and rehabilitation activities.

No matter how much money is appropriated, there will never beenough to provide all the services and support all the research whichwe might like. There will never be enough skilled manpower toexcuse needless duplication or needless overlapping.It is vital, therefore, that there be coordination of all alcoholismactivities within the Department. It is equally vital that Federalactivities he coordinated with those in States and lo,ral communi-ties, with those in hospitals, clinks, research centers, and teachinginstitutions, and with those of the voluntiiry agencies. It is vitalthat American work be coordinated with that abroad. It is vitalthat the developments in all these centers be conummicatcd asrapidly, accura tely and effectively as passible to health workers, toeducators, to government officials at every level, and to the public.What we are thus creating is a new and challenging partnershipwhich will cross rigid depaitmental, regional and even nationalboundaries, It mist also doss the equally rigid and sometimes morerestricting boundaries between the various professional and academicdisciplines . . If ever a partnership were needed to solve a majorpublic health problem, it is needed here in the attack againstalcoholism.

This new pattnership has now been created. 1 he needed manpower,the physical facilities, the techniques for delivery of services, and thefinancial support are being inobiliied.

The first big step has been taken.

61

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SUGGESTED SUPPLEMENTARY READINGBlock, Marvin A.: Alcoholism. Its Facets and Phases, John Day, New

York, 1965.Chafetz, Morris E.: Liquor, Servant of Man, Little, Brown, Boston, 1965.Jackson, Douglas: Stumbling Block, Board of Missions of the Methodist

Church, New York, 1960.Jellinek, E. M.: The Disease Concept of Alcoholism, Hillhouse Press,

Highland Park, N.J., 1960.Leake, Chauncey D., and Silverman, Milton: Alcoholic Beverages in

Clinical Medicine, Year Book Medical Publishers, Chicago, 1966.Lolli, Giorgio: Social Drinking, World, Cleveland, 1960.Lo 11i, Giorgio; Serianni, Emidio; Golder, Grace M.; and Luzzatto-Fegiz,

Pierpaolo: Alcohol in Italian Culture, Rutgers Center of Alcohol Studies,New Brunswick, N.J., 1958.

Lucia, Salvatore P. (ed.): Alcohol and Civilization, McGraw-Hill, NewYork, 1963.

Maddox, George L., and McCall, Bevode C.: Drinking among TermAgers, Rutgers Center of Alcohol Studies, New Brunswick, N.J., 1964.

Mann, Marty: New Primer on Alcoholism, Rinehart, New York, 1958.McCarthy, Raymond G. (ed.): Drinking and Intoxication, Rutgers Center

of Alcohol Studies, New Brunswick, N.J., 1959.McCarthy, Raymond G. (ed.): Alcohol Education for Classroom and

Community, McGra%.Hill, New York, 1961.Pittman, David J., and Snyder, Charles R. (eds.): Society, Culture, and

Drinking Patterns, Wiley, New Yolk, 1962.Rouech6, Berton: The Neutral Spirit: A Portrait of Alcohol, Little,

Brown, Boston, 1960.Sadoun, Roland; Lolli, Giorgio; and Silverman, Milton: Drinking in

French Culture, Rutgers Center of Alcohol Studies, New Brunswick, 1965.Snyder, Charles R.: Alcohol and the Jews, Rutgers Center of Alcohol

Studies, New Brunswick, N.J., 1958.Straus, Robert, and Bacon, Sclden D.: Drinking in College, Yale Uni-

versity Press, New Haven, 1953.

U. & COVE/0041NT PH TING OF FI : I .411 0 293-737

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